Healthcare Provider Details

I. General information

NPI: 1689959348
Provider Name (Legal Business Name): CORY RUSSELL CRECELIUS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2011
Last Update Date: 10/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 COUNTRY CLUB PKWY SUITE B
EUGENE OR
97401-6043
US

IV. Provider business mailing address

1624 W MAIN ST
JEFFERSON CITY MO
65109-1243
US

V. Phone/Fax

Practice location:
  • Phone: 541-683-5139
  • Fax: 514-683-5783
Mailing address:
  • Phone: 314-583-5553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6656
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: