MEDICARE: MR. TODD DOUGLAS FRARY LPTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	8494	OR

General Provider Information

NPI Number	:	1144468505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TODD DOUGLAS FRARY LPTA

Provider Business Mailing Address
First Line	:	1941 SW LAKE PL
Second Line	:
City	:	GRESHAM
State	:	OR
Zip	:	97080-9798
Country	:	US
Telephone Number	:	253-709-0271
Fax Number	:

Provider Business Practice Location Address
First Line	:	1941 SW LAKE PL
Second Line	:
City	:	GRESHAM
State	:	OR
Zip	:	97080-9798
Country	:	US
Telephone Number	:	253-709-0271
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2009
Last Update Date	:	11/10/2010

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