MEDICARE: THERESA RUFF-JOSUE IBCLC

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	174N00000X	Lactation Consultant (Non-RN)	LC-LC-10226469	OR

General Provider Information

NPI Number	:	1912622408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA RUFF-JOSUE IBCLC

Provider Business Mailing Address
First Line	:	20316 DONKEY SLED RD
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97702-2644
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2669 NE TWIN KNOLLS DR STE 103
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97701-4895
Country	:	US
Telephone Number	:	541-668-6210
Fax Number	:	541-668-6266

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

Provider Enumeration Date	:	10/06/2022
Last Update Date	:	12/26/2022

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