Basic Information
| Provider Information | |||||||||
| NPI: | 1548469158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUERST | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | JENIFER | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | L.M.T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 977 ROYAL AVE | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975046140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417798331 | ||||||||
| FaxNumber: | 5417790217 | ||||||||
| Practice Location | |||||||||
| Address1: | 977 ROYAL AVE | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975046140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417798331 | ||||||||
| FaxNumber: | 5417790217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2007 | ||||||||
| LastUpdateDate: | 07/13/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 14158 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.