Healthcare Provider Details

I. General information

NPI: 1235335001
Provider Name (Legal Business Name): LEON R DUNHAM LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 SW 2ND ST STE 4
CORVALLIS OR
97333-4650
US

IV. Provider business mailing address

734 SW 13TH ST
CORVALLIS OR
97333-4236
US

V. Phone/Fax

Practice location:
  • Phone: 541-753-8171
  • Fax:
Mailing address:
  • Phone: 541-753-8171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3961
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: