Provider Demographics
NPI:1619333689
Name:OWEN, LLOYD RUSSELL JR
Entity Type:Individual
Prefix:MR
First Name:LLOYD
Middle Name:RUSSELL
Last Name:OWEN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 PARADISE BAY RD
Mailing Address - Street 2:
Mailing Address - City:PORT LUDLOW
Mailing Address - State:WA
Mailing Address - Zip Code:98365-9771
Mailing Address - Country:US
Mailing Address - Phone:360-437-0809
Mailing Address - Fax:
Practice Address - Street 1:3205 PARADISE BAY RD
Practice Address - Street 2:
Practice Address - City:PORT LUDLOW
Practice Address - State:WA
Practice Address - Zip Code:98365-9771
Practice Address - Country:US
Practice Address - Phone:360-437-0809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60625873225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist