Provider Demographics
NPI:1790836948
Name:ENDRIES, TARA MICHELLE (LMT , ATC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MICHELLE
Last Name:ENDRIES
Suffix:
Gender:F
Credentials:LMT , ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20547 ROLEN AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2862
Mailing Address - Country:US
Mailing Address - Phone:541-350-5913
Mailing Address - Fax:541-330-0224
Practice Address - Street 1:20547 ROLEN AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-2862
Practice Address - Country:US
Practice Address - Phone:541-350-5913
Practice Address - Fax:541-330-0224
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6455247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other