Healthcare Provider Details

I. General information

NPI: 1124043633
Provider Name (Legal Business Name): EASTERN OREGON PHYSICAL THERAPY HERMISTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 N 1ST ST STE D
HERMISTON OR
97838-1682
US

IV. Provider business mailing address

PO BOX 90
SUNNYSIDE WA
98944-0090
US

V. Phone/Fax

Practice location:
  • Phone: 541-567-5678
  • Fax: 541-567-2110
Mailing address:
  • Phone: 541-567-5678
  • Fax: 541-567-2110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number110326-2401
License Number StateUT
# 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