Healthcare Provider Details

I. General information

NPI: 1881670198
Provider Name (Legal Business Name): CARLA K MCKIBBEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 11/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74B CENTENNIAL LOOP SUITE 300
EUGENE OR
97401-7918
US

IV. Provider business mailing address

74B CENTENNIAL LOOP SUITE 300
EUGENE OR
97401-7918
US

V. Phone/Fax

Practice location:
  • Phone: 541-686-3791
  • Fax: 541-686-3795
Mailing address:
  • Phone: 541-686-3791
  • Fax: 541-686-3795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3689
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier278721
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: