Provider Demographics
NPI:1871191981
Name:OUTSIDE MOVEMENT PHYSICAL THERAPY
Entity Type:Organization
Organization Name:OUTSIDE MOVEMENT PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:TODISCO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:802-318-2254
Mailing Address - Street 1:1645 NE SHEPARD RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4164
Mailing Address - Country:US
Mailing Address - Phone:802-318-2254
Mailing Address - Fax:
Practice Address - Street 1:1010 NW HARRIMAN ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-1912
Practice Address - Country:US
Practice Address - Phone:802-318-2254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy