Healthcare Provider Details

I. General information

NPI: 1790836948
Provider Name (Legal Business Name): TARA MICHELLE ENDRIES L.M.T. , A.T.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20547 ROLEN AVE
BEND OR
97702-2862
US

IV. Provider business mailing address

20547 ROLEN AVE
BEND OR
97702-2862
US

V. Phone/Fax

Practice location:
  • Phone: 541-350-5913
  • Fax: 541-330-0224
Mailing address:
  • Phone: 541-350-5913
  • Fax: 541-330-0224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number6455
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: