Provider Demographics
NPI:1609934504
Name:BRADSHAW PHYSICAL THERAPY & WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:BRADSHAW PHYSICAL THERAPY & WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:541-482-3126
Mailing Address - Street 1:223 WINTERSAGE CIR UNIT A
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540-9566
Mailing Address - Country:US
Mailing Address - Phone:541-482-3126
Mailing Address - Fax:541-482-0593
Practice Address - Street 1:223 WINTERSAGE CIR UNIT A
Practice Address - Street 2:
Practice Address - City:TALENT
Practice Address - State:OR
Practice Address - Zip Code:97540-9515
Practice Address - Country:US
Practice Address - Phone:541-482-3126
Practice Address - Fax:541-482-0593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21922251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR230041Medicaid
OR838049001OtherBCBS
OR122002900OtherUS DEPT. OF LABOR
ORL5250-01OtherPACIFICSOURCE
OR838049001OtherBCBS
OR230041Medicaid