Provider Demographics
NPI:1568685766
Name:SOUTHWEST PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:SOUTHWEST PHYSICAL THERAPY LLC
Other - Org Name:SOUTHWEST PHYSICAL THERAPY& JOHN BREUER REHABILITATION SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CORY
Authorized Official - Middle Name:
Authorized Official - Last Name:DORLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-269-7212
Mailing Address - Street 1:279 N CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:COQUILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97423-1241
Mailing Address - Country:US
Mailing Address - Phone:541-396-3341
Mailing Address - Fax:
Practice Address - Street 1:279 N CENTRAL ST
Practice Address - Street 2:
Practice Address - City:COQUILLE
Practice Address - State:OR
Practice Address - Zip Code:97423-1241
Practice Address - Country:US
Practice Address - Phone:541-396-3341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR207084Medicaid