Provider Demographics
NPI:1104501600
Name:CALDERA PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:CALDERA PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:D'AUTEUIL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:541-585-0313
Mailing Address - Street 1:16675 MASTEN MILL DR
Mailing Address - Street 2:
Mailing Address - City:LA PINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739-8708
Mailing Address - Country:US
Mailing Address - Phone:180-828-3259
Mailing Address - Fax:
Practice Address - Street 1:57031 PONDEROSA RD
Practice Address - Street 2:BLDG. 27 SUITE M2
Practice Address - City:SUNRIVER
Practice Address - State:OR
Practice Address - Zip Code:97707-8708
Practice Address - Country:US
Practice Address - Phone:541-585-0313
Practice Address - Fax:541-585-0312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-21
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty