Healthcare Provider Details

I. General information

NPI: 1275502056
Provider Name (Legal Business Name): JASON G LANOUETTE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 AUBURN STREET #103
PORTLAND ME
04103
US

IV. Provider business mailing address

3 CARNOUSTIE DRIVE
FALMOUTH ME
04105
US

V. Phone/Fax

Practice location:
  • Phone: 207-797-7578
  • Fax: 207-797-8165
Mailing address:
  • Phone: 207-878-8925
  • Fax: 207-797-8165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number799
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: