Healthcare Provider Details

I. General information

NPI: 1255111324
Provider Name (Legal Business Name): MOTION MEDIC PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2023
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 S 6TH ST
KLAMATH FALLS OR
97603-7111
US

IV. Provider business mailing address

6420 S 6TH ST
KLAMATH FALLS OR
97603-7111
US

V. Phone/Fax

Practice location:
  • Phone: 541-887-2090
  • Fax: 855-719-2480
Mailing address:
  • Phone: 541-887-2090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. VINCENT PAULO FORMALEJO PANGANIBAN
Title or Position: MANAGING MEMBER/OWNER
Credential: PT, DPT
Phone: 541-887-2090