Basic Information
| Provider Information | |||||||||
| NPI: | 1003058363 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALPINE PHYSICAL THERAPY & SPINE CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 336 SW CYBER DR | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977021683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413825500 | ||||||||
| FaxNumber: | 5413895669 | ||||||||
| Practice Location | |||||||||
| Address1: | 336 SW CYBER DR | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977021683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413825500 | ||||||||
| FaxNumber: | 5413895669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2009 | ||||||||
| LastUpdateDate: | 03/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | WEBER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5413825500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 274012 | 05 | OR | MEDICAID |