Healthcare Provider Details

I. General information

NPI: 1639392335
Provider Name (Legal Business Name): EUGENE W DESLAURIERS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 08/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 N HOWE ST SUITE 4
SOUTHPORT NC
28461-2770
US

IV. Provider business mailing address

3300 BOUGAINVILLE WAY
WILMINGTON NC
28409-2503
US

V. Phone/Fax

Practice location:
  • Phone: 910-454-8030
  • Fax:
Mailing address:
  • Phone: 910-454-8030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number3904
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3904
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: