Basic Information
| Provider Information | |||||||||
| NPI: | 1881054237 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAVIGNE | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | LAT, ATC, OTC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 551 LONE PINE BLVD | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970589403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415066500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 551 LONE PINE BLVD | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970589403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415066500 | ||||||||
| FaxNumber: | 5415066501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2016 | ||||||||
| LastUpdateDate: | 05/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZX2200X | N | 2255A2300X | AT-581 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.