Healthcare Provider Details

I. General information

NPI: 1659308633
Provider Name (Legal Business Name): DAMON OGLE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LA COLLEGE 1140 COLLEGE DR.
PINEVILLE LA
71359-0505
US

IV. Provider business mailing address

LA COLLEGE P.O. BOX 505
PINEVILLE LA
71359-0505
US

V. Phone/Fax

Practice location:
  • Phone: 318-487-7174
  • Fax:
Mailing address:
  • Phone: 318-487-7174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: