Healthcare Provider Details

I. General information

NPI: 1912715988
Provider Name (Legal Business Name): TYLER CIPRIAN BALDESSARI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 NE 4TH ST
BEND OR
97701-5162
US

IV. Provider business mailing address

1023 E CASCADE AVE
SISTERS OR
97759-9008
US

V. Phone/Fax

Practice location:
  • Phone: 541-668-7506
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number27843
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: