Healthcare Provider Details

I. General information

NPI: 1538644521
Provider Name (Legal Business Name): MICHAEL TIIDEBERG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2018
Last Update Date: 07/25/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31630 RAILROAD CANYON RD STE 4
CANYON LAKE CA
92587-9478
US

IV. Provider business mailing address

22724 LIGHTHOUSE DR
CANYON LAKE CA
92587-6904
US

V. Phone/Fax

Practice location:
  • Phone: 951-837-6980
  • Fax:
Mailing address:
  • Phone: 951-244-1434
  • Fax: 951-244-1434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95009382
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: