=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649653999
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENNIS DEMREST
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2015
-----------------------------------------------------
Last Update Date | 08/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 PARK AVE
-----------------------------------------------------
City | BROOKINGS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97415-9145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-303-2585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 PARK AVE
-----------------------------------------------------
City | BROOKINGS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97415-9145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-303-2585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2087393
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2306604562
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------