Healthcare Provider Details

I. General information

NPI: 1760400956
Provider Name (Legal Business Name): PIONEER MEMORIAL PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 11/13/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

695 S ALFALFA STREET
HEPPNER OR
97836-6300
US

IV. Provider business mailing address

PO BOX 70689
SALT LAKE CITY UT
84170-0689
US

V. Phone/Fax

Practice location:
  • Phone: 541-676-1123
  • Fax: 541-676-1122
Mailing address:
  • Phone: 801-987-8600
  • Fax: 801-987-8601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5020
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMANDA CARNINE
Title or Position: OWNER
Credential: PT
Phone: 406-531-5918