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General NPI Number Information
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NPI Number | 1730366998
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Entity Type | Individual
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Provider Name | MICHAEL BRYAN TRIPP SR. LMT
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Gender | Male
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Dates
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Enumeration Date | 01/29/2008
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Last Update Date | 01/29/2008
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Provider Practice Location Address
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Address Line | 411 WASHINGTON AVE
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City | COTTAGE GROVE
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State | OR
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Zip | 97424-2060
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Country | US
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Telephone | 541-554-7027
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Fax | 541-942-9849
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Provider Business Mailing Address
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Address Line | 411 WASHINGTON AVE
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City | COTTAGE GROVE
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State | OR
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Zip | 97424-2060
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Country | US
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Telephone | 541-554-7027
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Fax | 541-942-9849
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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 | 171W00000X
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Taxonomy Name | Contractor
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License Number | 11018
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License Number State | OR
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