Provider Demographics
NPI:1093121014
Name:TIDBALL, KELSI
Entity Type:Individual
Prefix:
First Name:KELSI
Middle Name:
Last Name:TIDBALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 COBURG RD STE 5
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-5200
Mailing Address - Country:US
Mailing Address - Phone:541-345-7532
Mailing Address - Fax:541-345-6692
Practice Address - Street 1:1310 COBURG RD STE 5
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-5200
Practice Address - Country:US
Practice Address - Phone:541-345-7532
Practice Address - Fax:541-345-6692
Is Sole Proprietor?:No
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16665174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist