Healthcare Provider Details

I. General information

NPI: 1194707042
Provider Name (Legal Business Name): EDWIN BENJAMIN MEELHUYSEN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2728 PHEASANT BLVD SUITE 100
SPRINGFIELD OR
97477-7589
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 541-736-8870
  • Fax: 541-736-8860
Mailing address:
  • Phone: 800-219-8835
  • Fax: 503-443-1402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2630
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: