Provider Demographics
NPI:1295154698
Name:BAGLEY, DALTON (LMT)
Entity type:Individual
Prefix:
First Name:DALTON
Middle Name:
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 ILLINOIS AVE NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4632
Mailing Address - Country:US
Mailing Address - Phone:503-991-2154
Mailing Address - Fax:
Practice Address - Street 1:14619 SW TEAL BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-6194
Practice Address - Country:US
Practice Address - Phone:503-746-6585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19467225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist