Healthcare Provider Details

I. General information

NPI: 1588592737
Provider Name (Legal Business Name): JOHN K LAVELLE PSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2026
Last Update Date: 05/09/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 MARION ST NE
SALEM OR
97301-3829
US

IV. Provider business mailing address

1173 S 10TH ST
INDEPENDENCE OR
97351-1563
US

V. Phone/Fax

Practice location:
  • Phone: 503-363-3660
  • Fax:
Mailing address:
  • Phone: 570-947-4492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number112409
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: