Basic Information
| Provider Information | |||||||||
| NPI: | 1699753095 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAJER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | Y | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT OCS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | O DONNELL | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | Y | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 12686 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973090686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035408701 | ||||||||
| FaxNumber: | 5033718772 | ||||||||
| Practice Location | |||||||||
| Address1: | 4677 COMMERCIAL ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973021901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035855131 | ||||||||
| FaxNumber: | 5035854065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 12/19/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2625 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 207105 | 05 | OR | MEDICAID |