Healthcare Provider Details

I. General information

NPI: 1326310335
Provider Name (Legal Business Name): JOSEPH R TIBAY RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2012
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 CHILOQUIN BLVD
CHILOQUIN OR
97624-6747
US

IV. Provider business mailing address

3949 SOUTH 6TH STREET
KLAMATH FALLS OR
97603
US

V. Phone/Fax

Practice location:
  • Phone: 541-882-1487
  • Fax: 541-783-3237
Mailing address:
  • Phone: 541-882-1487
  • Fax: 541-880-5590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number966795
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number966795
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: