Provider Demographics
NPI:1124043633
Name:EASTERN OREGON PHYSICAL THERAPY HERMISTON LLC
Entity type:Organization
Organization Name:EASTERN OREGON PHYSICAL THERAPY HERMISTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARNINE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:406-531-5918
Mailing Address - Street 1:PO BOX 90
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-0090
Mailing Address - Country:US
Mailing Address - Phone:541-567-5678
Mailing Address - Fax:541-567-2110
Practice Address - Street 1:1725 N 1ST ST STE D
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-1682
Practice Address - Country:US
Practice Address - Phone:541-567-5678
Practice Address - Fax:541-567-2110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2000X
UT110326-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR132238Medicare PIN