Provider Demographics
NPI:1871616920
Name:EGLESTON, DANIEL BLAINE (LMT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:BLAINE
Last Name:EGLESTON
Suffix:
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 1:277 W JONES CREEK RD
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-3606
Mailing Address - Country:US
Mailing Address - Phone:541-471-7245
Mailing Address - Fax:
Practice Address - Street 1:277 W JONES CREEK RD
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-3606
Practice Address - Country:US
Practice Address - Phone:541-471-7245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6506225700000X
WAMA00012185225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist