Provider Demographics
NPI:1811209919
Name:EDMISTON, LORA GENEVA (LMT)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:GENEVA
Last Name:EDMISTON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 NW NAITO PKWY
Mailing Address - Street 2:C-17
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3758
Mailing Address - Country:US
Mailing Address - Phone:503-860-5288
Mailing Address - Fax:
Practice Address - Street 1:604 NW 23RD AVE
Practice Address - Street 2:SUITE #2
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3209
Practice Address - Country:US
Practice Address - Phone:503-708-9049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14753225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist