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General NPI Number Information
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NPI Number | 1538644521
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Entity Type | Individual
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Provider Name | MICHAEL TIIDEBERG
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Gender | Male
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Dates
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Enumeration Date | 09/26/2018
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Last Update Date | 07/25/2022
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Provider Practice Location Address
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Address Line | 31630 RAILROAD CANYON RD STE 4
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City | CANYON LAKE
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State | CA
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Zip | 92587-9478
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Country | US
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Telephone | 951-837-6980
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Fax |
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Provider Business Mailing Address
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Address Line | 22724 LIGHTHOUSE DR
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City | CANYON LAKE
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State | CA
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Zip | 92587-6904
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Country | US
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Telephone | 951-244-1434
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Fax | 951-244-1434
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 95009382
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License Number State | CA
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