Provider Demographics
NPI:1003149485
Name:CORE PHYSICAL THERAPY AND SPINE LLC
Entity Type:Organization
Organization Name:CORE PHYSICAL THERAPY AND SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRASSFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:541-389-6595
Mailing Address - Street 1:336 SW CYBER DR STE 107
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1682
Mailing Address - Country:US
Mailing Address - Phone:541-389-6595
Mailing Address - Fax:
Practice Address - Street 1:336 SW CYBER DR STE 107
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1682
Practice Address - Country:US
Practice Address - Phone:541-389-6595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-16
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1543261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB32715Medicare PIN