Provider Demographics
NPI:1164980694
Name:TILLERY, MICHAEL (ATC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:TILLERY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 CONSTELLATION RD
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-1099
Mailing Address - Country:US
Mailing Address - Phone:805-742-2900
Mailing Address - Fax:805-742-2917
Practice Address - Street 1:4350 CONSTELLATION RD
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-1033
Practice Address - Country:US
Practice Address - Phone:805-742-2900
Practice Address - Fax:895-742-2917
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0704025162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer