Provider Demographics
NPI:1033857842
Name:FULCRUM OSTEOPATHIC, LLC
Entity Type:Organization
Organization Name:FULCRUM OSTEOPATHIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:EVITTS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:541-250-5994
Mailing Address - Street 1:525 NW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-6487
Mailing Address - Country:US
Mailing Address - Phone:541-250-5994
Mailing Address - Fax:541-638-4002
Practice Address - Street 1:525 NW 2ND ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-6487
Practice Address - Country:US
Practice Address - Phone:541-250-5994
Practice Address - Fax:541-638-4002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-23
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287713Medicaid