Provider Demographics
NPI:1770723363
Name:GRAFTON, GORDON WAYNE JR (LMT)
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:WAYNE
Last Name:GRAFTON
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:MR
Other - First Name:WAYNE
Other - Middle Name:GORDON
Other - Last Name:GRAFTON
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:832 E MAIN ST
Mailing Address - Street 2:5
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7153
Mailing Address - Country:US
Mailing Address - Phone:541-201-0224
Mailing Address - Fax:541-857-4011
Practice Address - Street 1:832 E MAIN ST
Practice Address - Street 2:5
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7153
Practice Address - Country:US
Practice Address - Phone:541-201-0224
Practice Address - Fax:541-857-4011
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7494225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist