Provider Demographics
NPI:1083838478
Name:EMERALD VALLEY PHYSICAL THERAPY, P.C.
Entity Type:Organization
Organization Name:EMERALD VALLEY PHYSICAL THERAPY, P.C.
Other - Org Name:DRAIN PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:FEOLA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:541-895-2863
Mailing Address - Street 1:32571 CAMAS SWALE RD
Mailing Address - Street 2:
Mailing Address - City:CRESWELL
Mailing Address - State:OR
Mailing Address - Zip Code:97426-9832
Mailing Address - Country:US
Mailing Address - Phone:541-895-2863
Mailing Address - Fax:541-895-5204
Practice Address - Street 1:600 DALE KUNI RD STE 170
Practice Address - Street 2:
Practice Address - City:CRESWELL
Practice Address - State:OR
Practice Address - Zip Code:97426-8703
Practice Address - Country:US
Practice Address - Phone:541-895-2216
Practice Address - Fax:541-895-5204
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMERALD VALLEY PHYSICAL THERAPY, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-13
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPENDINGMedicare ID - Type UnspecifiedAPPLIED FOR