Healthcare Provider Details

I. General information

NPI: 1235334244
Provider Name (Legal Business Name): JED MICHAEL LAUTERS PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4242 COMMERCE ST STE A
EUGENE OR
97402-5412
US

IV. Provider business mailing address

11481 SW HALL BLVD STE 201
PORTLAND OR
97223-8403
US

V. Phone/Fax

Practice location:
  • Phone: 541-484-9632
  • Fax: 541-484-7466
Mailing address:
  • Phone: 800-219-8835
  • Fax: 503-443-1402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5420
License Number StateOR

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: