Healthcare Provider Details

I. General information

NPI: 1578130159
Provider Name (Legal Business Name): PETER JOSEPH TUTHILL LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 06/10/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2031 NE DIAMOND LAKE BLVD
ROSEBURG OR
97470-3574
US

IV. Provider business mailing address

1820 LARSON RD.
ROSEBURG OR
97471
US

V. Phone/Fax

Practice location:
  • Phone: 541-430-1727
  • Fax:
Mailing address:
  • Phone: 541-430-1727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number23969
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: