Provider Demographics
NPI:1447495601
Name:DEAUSTRIA, RICARDO M JR (LMT)
Entity type:Individual
Prefix:MR
First Name:RICARDO
Middle Name:M
Last Name:DEAUSTRIA
Suffix:JR
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 1:2701 NW VAUGHN ST STE 154
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5349
Mailing Address - Country:US
Mailing Address - Phone:503-719-4326
Mailing Address - Fax:
Practice Address - Street 1:2701 NW VAUGHN ST STE 154
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5349
Practice Address - Country:US
Practice Address - Phone:503-719-4326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15490172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist