Provider Demographics
NPI:1376992594
Name:MOJO PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:MOJO PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:THOMASON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:541-915-3811
Mailing Address - Street 1:2211 NW PROFESSIONAL DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3891
Mailing Address - Country:US
Mailing Address - Phone:541-207-3720
Mailing Address - Fax:541-207-3729
Practice Address - Street 1:2211 NW PROFESSIONAL DR
Practice Address - Street 2:SUITE 204
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3891
Practice Address - Country:US
Practice Address - Phone:541-207-3720
Practice Address - Fax:541-207-3729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-08
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60894261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR189553Medicare PIN