Provider Demographics
NPI:1801278049
Name:DECKER, DARREL A (PTA)
Entity type:Individual
Prefix:
First Name:DARREL
Middle Name:A
Last Name:DECKER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 SE BETHEL PLACE
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333
Mailing Address - Country:US
Mailing Address - Phone:812-585-2768
Mailing Address - Fax:
Practice Address - Street 1:350 8TH STREET
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355
Practice Address - Country:US
Practice Address - Phone:541-259-1221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR08867314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility