Basic Information
Provider Information | |||||||||
NPI: | 1952379273 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HIGH DESERT THERAPY ASSOCIATES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LAPINE PHYSICAL THERAPY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1888 | ||||||||
Address2: |   | ||||||||
City: | LA PINE | ||||||||
State: | OR | ||||||||
PostalCode: | 977391888 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5415366122 | ||||||||
FaxNumber: | 5415366123 | ||||||||
Practice Location | |||||||||
Address1: | 51681 HUNTINGTON ROAD | ||||||||
Address2: |   | ||||||||
City: | LAPINE | ||||||||
State: | OR | ||||||||
PostalCode: | 97739 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5415366122 | ||||||||
FaxNumber: | 5415366123 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/11/2006 | ||||||||
LastUpdateDate: | 04/28/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SMITH | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | PHILIP | ||||||||
AuthorizedOfficialTitleorPosition: | TREASURER BUSINESS MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5415938535 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.