Healthcare Provider Details

I. General information

NPI: 1275728396
Provider Name (Legal Business Name): CHRISTINE M BODNER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINE M BODNER-NYBURG DPT

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 01/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 LINCOLN ST STE 230
EUGENE OR
97401-6021
US

IV. Provider business mailing address

390 LINCOLN ST STE 230
EUGENE OR
97401-6021
US

V. Phone/Fax

Practice location:
  • Phone: 541-255-2095
  • Fax: 541-255-2445
Mailing address:
  • Phone: 541-255-2095
  • Fax: 541-255-2445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5500
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier218696
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
IdentifierR190152
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerMEDICARE PTAN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: