Provider Demographics
NPI:1760109573
Name:VONDETTE, MICHAEL JOHN (CRM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:VONDETTE
Suffix:
Gender:M
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17818
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-7818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 FRONT ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-1089
Practice Address - Country:US
Practice Address - Phone:503-363-2021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22-CRM-1365175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist