Provider Demographics
NPI:1871902031
Name:DAVIS, LAURIE (ORT)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:ORT
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:
Other - Last Name:GALLUP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICENSED INSURANCE A
Mailing Address - Street 1:711 MEDFORD CTR
Mailing Address - Street 2:#318
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6772
Mailing Address - Country:US
Mailing Address - Phone:541-840-4426
Mailing Address - Fax:
Practice Address - Street 1:711 MEDFORD CTR
Practice Address - Street 2:#318
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6772
Practice Address - Country:US
Practice Address - Phone:541-840-4426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist