Provider Demographics
NPI:1710134861
Name:EIDE, MICHELLE R (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:R
Last Name:EIDE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:683 JUNE DR
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038-9281
Mailing Address - Country:US
Mailing Address - Phone:503-351-7896
Mailing Address - Fax:503-829-7640
Practice Address - Street 1:683 JUNE DR
Practice Address - Street 2:
Practice Address - City:MOLALLA
Practice Address - State:OR
Practice Address - Zip Code:97038-9281
Practice Address - Country:US
Practice Address - Phone:503-351-7896
Practice Address - Fax:503-829-7640
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14804171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor