Healthcare Provider Details

I. General information

NPI: 1548681547
Provider Name (Legal Business Name): PROMOTION PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2013
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 NW DELAWARE AVE SUITE 102
BEND OR
97701-3276
US

IV. Provider business mailing address

PO BOX 72
BEND OR
97709-0072
US

V. Phone/Fax

Practice location:
  • Phone: 541-788-7788
  • Fax:
Mailing address:
  • Phone: 541-788-7788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2366
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: WILLIAM BLAKE MATLOCK
Title or Position: OWNER
Credential:
Phone: 541-788-7788