Provider Demographics
NPI:1245234285
Name:CENTRAL CASCADES PHYSICAL THERAPY
Entity Type:Organization
Organization Name:CENTRAL CASCADES PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:
Authorized Official - First Name:GROVER
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:COCKRUM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:541-576-2110
Mailing Address - Street 1:PO BOX 4520
Mailing Address - Street 2:
Mailing Address - City:SUNRIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97707-1520
Mailing Address - Country:US
Mailing Address - Phone:541-576-2110
Mailing Address - Fax:541-598-0489
Practice Address - Street 1:87520 BAY ROAD
Practice Address - Street 2:
Practice Address - City:CHRISTMAS VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97641-0001
Practice Address - Country:US
Practice Address - Phone:541-576-2110
Practice Address - Fax:541-598-0489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1385225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR808366001OtherREGENCE BLUECROSS/BLUESHI
OR269080Medicaid
OR808366001OtherREGENCE BLUECROSS/BLUESHI