Healthcare Provider Details

I. General information

NPI: 1609843317
Provider Name (Legal Business Name): EILEEN MACKLE TOKUDA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 MAIN ST
PHILOMATH OR
97370-9725
US

IV. Provider business mailing address

732 MAIN ST PO BOX 1360
PHILOMATH OR
97370-9725
US

V. Phone/Fax

Practice location:
  • Phone: 541-929-2255
  • Fax: 541-929-7055
Mailing address:
  • Phone: 541-929-2255
  • Fax: 541-929-7055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0736
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: