Provider Demographics
NPI:1306204409
Name:CAIN, ANGELA (MS ATC, PTA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:CAIN
Suffix:
Gender:F
Credentials:MS ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 Y AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-2749
Mailing Address - Country:US
Mailing Address - Phone:541-350-3431
Mailing Address - Fax:
Practice Address - Street 1:2519 COVE AVE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-3910
Practice Address - Country:US
Practice Address - Phone:541-962-0830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9957208100000X
OR20000173822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR9957Medicaid