Healthcare Provider Details

I. General information

NPI: 1053607259
Provider Name (Legal Business Name): SWEETGRASS PHYSICAL THERAPY & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2011
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 NW SPRUCE AVE
CORVALLIS OR
97330-2234
US

IV. Provider business mailing address

971 NW SPRUCE AVE
CORVALLIS OR
97330-2234
US

V. Phone/Fax

Practice location:
  • Phone: 541-207-3436
  • Fax: 541-207-3284
Mailing address:
  • Phone: 406-450-8218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DANA K. HUGHES
Title or Position: MEMBER
Credential: PT
Phone: 406-450-8218