Basic Information
Provider Information
NPI: 1932187689
EntityType: 2
ReplacementNPI:  
OrganizationName: BEND PHYSICAL THERAPY ASSOCIATES
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: TAI CENTRAL OREGON REDMOND
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 11481 SW HALL BLVD
Address2: SUITE 201
City: PORTLAND
State: OR
PostalCode: 972238403
CountryCode: US
TelephoneNumber: 8002198835
FaxNumber: 5034431402
Practice Location
Address1: 413 NW LARCH AVE
Address2: SUITE 102
City: REDMOND
State: OR
PostalCode: 977561361
CountryCode: US
TelephoneNumber: 5419237494
FaxNumber: 5415049153
Other Information
ProviderEnumerationDate: 01/04/2006
LastUpdateDate: 09/09/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: GIFFORD
AuthorizedOfficialFirstName: TODD
AuthorizedOfficialMiddleName: ROBERT
AuthorizedOfficialTitleorPosition: COO
AuthorizedOfficialTelephone: 8002198835
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: PT
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225X00000X ORN193200000X MULTI-SPECIALTY GROUPRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist 
225100000X ORY193200000X MULTI-SPECIALTY GROUPRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

ID Information
IDTypeStateIssuerDescription
19767100001OROWCPOTHER


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