Healthcare Provider Details

I. General information

NPI: 1295710143
Provider Name (Legal Business Name): BEND PHYSICAL THERAPY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 DESPERADO TRL SUITE 201
SISTERS OR
97759-9580
US

IV. Provider business mailing address

11481 SW HALL BLVD SUITE 201
PORTLAND OR
97223-8403
US

V. Phone/Fax

Practice location:
  • Phone: 541-549-3574
  • Fax: 541-549-1092
Mailing address:
  • Phone: 800-219-8836
  • Fax: 503-639-9699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateOR

VIII. Authorized Official

Name: MR. TODD ROBERT GIFFORD
Title or Position: COO
Credential: PT
Phone: 800-219-8835