Healthcare Provider Details

I. General information

NPI: 1023083979
Provider Name (Legal Business Name): BYRON J. HERIGSTAD PT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120-C N EVEREST RD
NEWBERG OR
97132
US

IV. Provider business mailing address

20400 NE NIEDERBERGER RD
DUNDEE OR
97115-9005
US

V. Phone/Fax

Practice location:
  • Phone: 503-538-8952
  • Fax: 503-537-2027
Mailing address:
  • Phone: 503-538-5841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1549
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: