Healthcare Provider Details

I. General information

NPI: 1649653999
Provider Name (Legal Business Name): DENNIS DEMREST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2015
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PARK AVE
BROOKINGS OR
97415-9145
US

IV. Provider business mailing address

1 PARK AVE
BROOKINGS OR
97415-9145
US

V. Phone/Fax

Practice location:
  • Phone: 757-303-2585
  • Fax:
Mailing address:
  • Phone: 757-303-2585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2087393
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306604562
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: