Provider Demographics
NPI:1760400956
Name:PIONEER MEMORIAL PHYSICAL THERAPY
Entity type:Organization
Organization Name:PIONEER MEMORIAL PHYSICAL THERAPY
Other - Org Name:<UNAVAIL>
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 70689
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84170-0689
Mailing Address - Country:US
Mailing Address - Phone:801-987-8600
Mailing Address - Fax:801-987-8601
Practice Address - Street 1:695 S ALFALFA STREET
Practice Address - Street 2:
Practice Address - City:HEPPNER
Practice Address - State:OR
Practice Address - Zip Code:97836-6300
Practice Address - Country:US
Practice Address - Phone:541-676-1123
Practice Address - Fax:541-676-1122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2000X
OR5020225100000X
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
ORR132259Medicare PIN