Healthcare Provider Details

I. General information

NPI: 1245789130
Provider Name (Legal Business Name): STARTING LINE PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1957 THOMPSON RD STE A
COOS BAY OR
97420
US

IV. Provider business mailing address

1957 THOMPSON RD STE A
COOS BAY OR
97420
US

V. Phone/Fax

Practice location:
  • Phone: 541-266-7050
  • Fax: 541-266-0180
Mailing address:
  • Phone: 541-266-7050
  • Fax: 541-266-0180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number4529
License Number StateOR

VIII. Authorized Official

Name: JULIETTE L HYATT
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: PT
Phone: 541-266-7050