Healthcare Provider Details

I. General information

NPI: 1871191981
Provider Name (Legal Business Name): OUTSIDE MOVEMENT PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 10/12/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 NW HARRIMAN ST
BEND OR
97703-1912
US

IV. Provider business mailing address

1645 NE SHEPARD RD
BEND OR
97701-4164
US

V. Phone/Fax

Practice location:
  • Phone: 802-318-2254
  • Fax:
Mailing address:
  • Phone: 802-318-2254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

VIII. Authorized Official

Name: NICOLE TODISCO
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: PT
Phone: 802-318-2254