Healthcare Provider Details

I. General information

NPI: 1205344405
Provider Name (Legal Business Name): EOPT BOARDMAN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SW KINKADE RD
BOARDMAN OR
97818-9001
US

IV. Provider business mailing address

PO BOX 540640
NORTH SALT LAKE UT
84054-0640
US

V. Phone/Fax

Practice location:
  • Phone: 541-481-2533
  • Fax: 541-314-4448
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMANDA CARNINE
Title or Position: OWNER
Credential: PT
Phone: 406-531-5918