Provider Demographics
NPI:1760400956
Name:PIONEER MEMORIAL PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PIONEER MEMORIAL PHYSICAL THERAPY
Other - Org Name:PIONEER MEMORIAL PHYSICAL THERAPY LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:G
Authorized Official - Last Name:WORTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:801-417-5017
Mailing Address - Street 1:PO BOX 70689
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84170-0689
Mailing Address - Country:US
Mailing Address - Phone:801-987-8600
Mailing Address - Fax:801-987-8601
Practice Address - Street 1:150 ROCK ST
Practice Address - Street 2:
Practice Address - City:HEPPNER
Practice Address - State:OR
Practice Address - Zip Code:97836-7309
Practice Address - Country:US
Practice Address - Phone:541-676-2945
Practice Address - Fax:541-676-2938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5020225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR132259Medicare PIN