Provider Demographics
NPI:1720071897
Name:CHAMBERS, BRIAN KEITH (MPT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:CHAMBERS
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-0307
Mailing Address - Country:US
Mailing Address - Phone:801-294-6907
Mailing Address - Fax:801-294-6917
Practice Address - Street 1:1100 SOUTHGATE
Practice Address - Street 2:#1
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-3974
Practice Address - Country:US
Practice Address - Phone:541-276-4011
Practice Address - Fax:541-278-2327
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3672225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227840Medicaid
OR227840Medicaid