Healthcare Provider Details

I. General information

NPI: 1366066748
Provider Name (Legal Business Name): EVERETT PLOCEK DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N 1ST AVE
STAYTON OR
97383-1704
US

IV. Provider business mailing address

279 CHESTNUT ST
LOUISVILLE CO
80027-2624
US

V. Phone/Fax

Practice location:
  • Phone: 503-769-3123
  • Fax: 503-769-3176
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number63696
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: