Provider Demographics
NPI:1104348861
Name:VAN LOO, MACKENZIE (PT)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:VAN LOO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:CURREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1517
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-0410
Mailing Address - Country:US
Mailing Address - Phone:877-708-1119
Mailing Address - Fax:541-278-8349
Practice Address - Street 1:336 SW CYBER DR STE 107
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702
Practice Address - Country:US
Practice Address - Phone:541-382-5500
Practice Address - Fax:541-389-5669
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62296225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500729554Medicaid
ORR195657OtherMEDICARE