Healthcare Provider Details

I. General information

NPI: 1033857842
Provider Name (Legal Business Name): FULCRUM OSTEOPATHIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2022
Last Update Date: 12/29/2023
Certification Date: 12/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 NW 2ND ST
CORVALLIS OR
97330-6487
US

IV. Provider business mailing address

525 NW 2ND ST
CORVALLIS OR
97330-6487
US

V. Phone/Fax

Practice location:
  • Phone: 541-250-5994
  • Fax: 541-638-4002
Mailing address:
  • Phone: 541-250-5994
  • Fax: 541-638-4002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW PATRICK EVITTS
Title or Position: OWNER/MEMBER
Credential: DO
Phone: 541-250-5994