Provider Demographics
NPI:1346846565
Name:PRIME PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PRIME PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BALCITA
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT, DPT, CSCS
Authorized Official - Phone:541-974-8572
Mailing Address - Street 1:1205 MARCUS WAY
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5782
Mailing Address - Country:US
Mailing Address - Phone:541-974-8572
Mailing Address - Fax:
Practice Address - Street 1:337 UNION AVE STE D
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5574
Practice Address - Country:US
Practice Address - Phone:541-974-8572
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty