Provider Demographics
NPI:1316007636
Name:IVINS, DARYL L (PT)
Entity type:Individual
Prefix:MR
First Name:DARYL
Middle Name:L
Last Name:IVINS
Suffix:
Gender:M
Credentials:PT
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Mailing Address - Street 1:4132 DEVONSHIRE CT NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1982
Mailing Address - Country:US
Mailing Address - Phone:503-371-4800
Mailing Address - Fax:503-371-4801
Practice Address - Street 1:4132 DEVONSHIRE CT NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1982
Practice Address - Country:US
Practice Address - Phone:503-371-4800
Practice Address - Fax:503-371-4801
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OR3584225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR11-3708203OtherHEALTHNET
OR831552000OtherBLUE CROSS PPP
ORJ 2333-01OtherPACIFICSOURCE
OR113708203OtherLIFEWISE
OR500113701OtherBLUE CROSS - ACCESS BLUE
OR500113701OtherFIRST CHOICE 65
OR500113701OtherBLUE CROSS - ACCESS BLUE