Healthcare Provider Details

I. General information

NPI: 1215929591
Provider Name (Legal Business Name): MICHAEL THOMAS WISE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 02/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 SW 9TH ST
REDMOND OR
97756-2726
US

IV. Provider business mailing address

707 SW 9TH ST
REDMOND OR
97756
US

V. Phone/Fax

Practice location:
  • Phone: 541-728-0085
  • Fax: 541-504-5353
Mailing address:
  • Phone: 541-548-5089
  • Fax: 541-504-5353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3915
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: