Healthcare Provider Details

I. General information

NPI: 1114097649
Provider Name (Legal Business Name): RICHARD EUGENE LAGUE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HFC DIXON RECREATION CENTER OREGON STATE UNIVERSITY
CORVALLIS OR
97331
US

IV. Provider business mailing address

630 SW 2ND ST
CORVALLIS OR
97333-4442
US

V. Phone/Fax

Practice location:
  • Phone: 541-737-7556
  • Fax:
Mailing address:
  • Phone: 541-757-2726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number0772
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT00002123
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: