Healthcare Provider Details

I. General information

NPI: 1285303529
Provider Name (Legal Business Name): PHYSICALITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 09/09/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7128 MAPLEWOOD DR SE
TURNER OR
97392-7903
US

IV. Provider business mailing address

7128 MAPLEWOOD DR SE
TURNER OR
97392-7903
US

V. Phone/Fax

Practice location:
  • Phone: 541-510-3622
  • Fax:
Mailing address:
  • Phone: 541-510-3622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: NICHOLAS JAMES SIEWERT
Title or Position: OWNER
Credential: DPT
Phone: 541-510-3622