Basic Information
| Provider Information | |||||||||
| NPI: | 1225773930 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LORETH | ||||||||
| FirstName: | GAIL | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | GAIL | ||||||||
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| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 563 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974529727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413567080 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1735 ADKINS ST | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974015003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416835032 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2022 | ||||||||
| LastUpdateDate: | 04/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA-19954 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | 9741 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.