Provider Demographics
NPI:1548681547
Name:PROMOTION PHYSICAL THERAPY
Entity type:Organization
Organization Name:PROMOTION PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:MATLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-788-7788
Mailing Address - Street 1:PO BOX 72
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-0072
Mailing Address - Country:US
Mailing Address - Phone:541-788-7788
Mailing Address - Fax:
Practice Address - Street 1:845 NW DELAWARE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3276
Practice Address - Country:US
Practice Address - Phone:541-788-7788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2366261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR156520Medicare PIN