Provider Demographics
NPI:1043680796
Name:BLEVINS, LAURA (ND)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BLEVINS
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4036 S 6TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-4750
Mailing Address - Country:US
Mailing Address - Phone:541-851-9320
Mailing Address - Fax:541-851-9322
Practice Address - Street 1:4036 S 6TH ST STE 2
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-4750
Practice Address - Country:US
Practice Address - Phone:541-851-9320
Practice Address - Fax:541-851-9322
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3053175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500694147Medicaid