Provider Demographics
NPI:1174567952
Name:CASCADE REHABILITATION ASSOCIATES, PC
Entity type:Organization
Organization Name:CASCADE REHABILITATION ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MS PT
Authorized Official - Phone:541-923-1436
Mailing Address - Street 1:735 SW 11TH ST
Mailing Address - Street 2:STE 103
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-9592
Mailing Address - Country:US
Mailing Address - Phone:541-923-1436
Mailing Address - Fax:541-923-1467
Practice Address - Street 1:735 SW 11TH ST
Practice Address - Street 2:STE 103
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2649
Practice Address - Country:US
Practice Address - Phone:541-923-1436
Practice Address - Fax:541-923-1467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0908225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR233502Medicaid
OR05-4082000OtherBLUE CROSS BLUE SHIELD
OR233502Medicaid