Healthcare Provider Details

I. General information

NPI: 1639650054
Provider Name (Legal Business Name): PINNACLE ORTHOTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 COBURG RD STE 7
EUGENE OR
97401-5200
US

IV. Provider business mailing address

1310 COBURG RD STE 7
EUGENE OR
97401-5200
US

V. Phone/Fax

Practice location:
  • Phone: 541-654-9447
  • Fax: 541-972-2018
Mailing address:
  • Phone: 541-654-9447
  • Fax: 541-972-2018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224L00000X
TaxonomyPedorthist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
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: JARRED NATHANIAL GIBSON
Title or Position: OWNER
Credential: MS, ATC, C.PED
Phone: 541-654-9447