Provider Demographics
NPI:1467411082
Name:INSTITUTE FOR PHYSICAL WELLNESS AND INDEPENDENCE
Entity Type:Organization
Organization Name:INSTITUTE FOR PHYSICAL WELLNESS AND INDEPENDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-344-8469
Mailing Address - Street 1:PO BOX 849095
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-9095
Mailing Address - Country:US
Mailing Address - Phone:541-344-8469
Mailing Address - Fax:541-687-8631
Practice Address - Street 1:2401 RIVER RD
Practice Address - Street 2:STE 101
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404
Practice Address - Country:US
Practice Address - Phone:541-344-8469
Practice Address - Fax:541-687-8631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR132174Medicare ID - Type Unspecified