Provider Demographics
NPI:1063647444
Name:KELLOW, LARS EDWARD (DPT)
Entity Type:Individual
Prefix:MR
First Name:LARS
Middle Name:EDWARD
Last Name:KELLOW
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9316 SW CORAL ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6663
Mailing Address - Country:US
Mailing Address - Phone:541-760-7794
Mailing Address - Fax:
Practice Address - Street 1:11850 SW ALLEN BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-4805
Practice Address - Country:US
Practice Address - Phone:503-646-7164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist