MEDICARE: MARISA MICHAEL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	LD-D-10165162	OR

General Provider Information

NPI Number	:	1295131118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISA MICHAEL

Provider Business Mailing Address
First Line	:	2599 DEBOK CT
Second Line	:
City	:	WEST LINN
State	:	OR
Zip	:	97068-7300
Country	:	US
Telephone Number	:	503-303-7951
Fax Number	:

Provider Business Practice Location Address
First Line	:	2599 DEBOK CT
Second Line	:
City	:	WEST LINN
State	:	OR
Zip	:	97068-7300
Country	:	US
Telephone Number	:	503-303-7951
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2014
Last Update Date	:	11/05/2014

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