Healthcare Provider Details

I. General information

NPI: 1619377579
Provider Name (Legal Business Name): WALTER CARELL III LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2014
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 CHARNELTON ST STE 7
EUGENE OR
97401-6206
US

IV. Provider business mailing address

4200 BERRYWOOD DR
EUGENE OR
97404-7001
US

V. Phone/Fax

Practice location:
  • Phone: 541-554-2730
  • Fax:
Mailing address:
  • Phone: 541-554-2730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number20737
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier20737
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerMASSAGE THERAPIST

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: