Healthcare Provider Details

I. General information

NPI: 1649090028
Provider Name (Legal Business Name): JUAN DAVID TELLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2024
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 LINCOLN ST
EUGENE OR
97401-2516
US

IV. Provider business mailing address

557 MARY NEAL LN
CRESWELL OR
97426-9555
US

V. Phone/Fax

Practice location:
  • Phone: 503-809-9741
  • Fax:
Mailing address:
  • Phone: 651-485-2589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: