Provider Demographics
NPI:1639530249
Name:PRO MOTION PHYSICAL THERAPY OF BEND
Entity Type:Organization
Organization Name:PRO MOTION PHYSICAL THERAPY OF BEND
Other - Org Name:PROMOTION PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:MATLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MSPT
Authorized Official - Phone:541-390-0523
Mailing Address - Street 1:PO BOX 72
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-0072
Mailing Address - Country:US
Mailing Address - Phone:541-390-0523
Mailing Address - Fax:541-787-4383
Practice Address - Street 1:1693 SW CHANDLER AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3236
Practice Address - Country:US
Practice Address - Phone:541-390-0523
Practice Address - Fax:541-787-4383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-09
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR043662251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty