Healthcare Provider Details

I. General information

NPI: 1912868225
Provider Name (Legal Business Name): PACIFIC SPORTS AND INTERVENTIONAL SPINE, LLC-P
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2025
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 WILLAMETTE ST STE 302
EUGENE OR
97401-4593
US

IV. Provider business mailing address

1711 WILLAMETTE ST STE 302
EUGENE OR
97401-4593
US

V. Phone/Fax

Practice location:
  • Phone: 541-780-6654
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KRISTIN BUNCH
Title or Position: DIRECTOR OF CONTRACTING/CRED
Credential:
Phone: 503-953-0357