Basic Information
| Provider Information | |||||||||
| NPI: | 1760400956 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PIONEER MEMORIAL PHYSICAL THERAPY | ||||||||
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| OtherOrganizationName: | PIONEER MEMORIAL PHYSICAL THERAPY LLC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 70689 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841700689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019878600 | ||||||||
| FaxNumber: | 8019878601 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 ROCK ST | ||||||||
| Address2: | |||||||||
| City: | HEPPNER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978367309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416762945 | ||||||||
| FaxNumber: | 5416762938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 08/07/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WORTLEY | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8014175017 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5020 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.