Healthcare Provider Details

I. General information

NPI: 1639841588
Provider Name (Legal Business Name): LEG UP LYMPHEDEMA CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2021
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W 32ND ST
VANCOUVER WA
98660-2163
US

IV. Provider business mailing address

611 W 32ND ST
VANCOUVER WA
98660-2163
US

V. Phone/Fax

Practice location:
  • Phone: 503-295-3602
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS VARENAS
Title or Position: PROPRIETOR
Credential: OTR/L
Phone: 503-295-3602