Provider Demographics
NPI:1093589798
Name:CORVALLIS CLINIC PC
Entity Type:Organization
Organization Name:CORVALLIS CLINIC PC
Other - Org Name:CORVALLIS CLINIC PHYSICAL THERAPY HERITAGE MALL DME ONLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:KAECH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-754-1374
Mailing Address - Street 1:444 NW ELKS DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3745
Mailing Address - Country:US
Mailing Address - Phone:541-754-1374
Mailing Address - Fax:
Practice Address - Street 1:1815 14TH AVE SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-8502
Practice Address - Country:US
Practice Address - Phone:541-754-1265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORVALLIS CLINIC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-11-13
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies