Provider Demographics
NPI:1184221335
Name:CONVERGENCE PHYSICAL THERAPY AND PERFORMANCE
Entity type:Organization
Organization Name:CONVERGENCE PHYSICAL THERAPY AND PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:TANAKA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:808-392-0058
Mailing Address - Street 1:224 W 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-3312
Mailing Address - Country:US
Mailing Address - Phone:808-392-0058
Mailing Address - Fax:
Practice Address - Street 1:303 S 5TH ST STE 140
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-5480
Practice Address - Country:US
Practice Address - Phone:541-625-0191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy