Healthcare Provider Details

I. General information

NPI: 1881186336
Provider Name (Legal Business Name): PACIFIC SPORTS AND INTERVENTIONAL SPINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 DIVISION AVE
EUGENE OR
97404-5429
US

IV. Provider business mailing address

2445 BEVERLY ST STE B
SPRINGFIELD OR
97477-1910
US

V. Phone/Fax

Practice location:
  • Phone: 541-686-3791
  • Fax: 541-686-3795
Mailing address:
  • Phone: 541-743-9003
  • Fax: 541-284-0520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00420
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberMD28629
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA152998
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00800
License Number StateOR
# 5
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberMD27887
License Number StateOR

VIII. Authorized Official

Name: LESLIE REA
Title or Position: PRACTICE MANAGER
Credential:
Phone: 541-743-9003