Healthcare Provider Details

I. General information

NPI: 1194192021
Provider Name (Legal Business Name): MINDA MCCULLOUGH-YRAY MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2015
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1754 SW EASY ST
CORVALLIS OR
97333-1762
US

IV. Provider business mailing address

1754 SW EASY ST
CORVALLIS OR
97333-1762
US

V. Phone/Fax

Practice location:
  • Phone: 530-632-2146
  • Fax:
Mailing address:
  • Phone: 530-632-2146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number10169784
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: