Healthcare Provider Details

I. General information

NPI: 1720320336
Provider Name (Legal Business Name): BUDDY LEE PURVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2013
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 CAL YOUNG RD APT 92
EUGENE OR
97401-2018
US

IV. Provider business mailing address

1814 CAL YOUNG RD APT 92
EUGENE OR
97401-2018
US

V. Phone/Fax

Practice location:
  • Phone: 541-214-4967
  • Fax:
Mailing address:
  • Phone: 541-214-4967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLMT-19235
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number19235
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: