Provider Demographics
NPI:1184699738
Name:DIEDE, MIKE TODD (ATC)
Entity type:Individual
Prefix:DR
First Name:MIKE
Middle Name:TODD
Last Name:DIEDE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1500 UNIVERSITY DR
Mailing Address - Street 2:PE 109
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-0245
Mailing Address - Country:US
Mailing Address - Phone:406-657-2351
Mailing Address - Fax:406-657-2399
Practice Address - Street 1:2178 BRIDGER DR
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-9469
Practice Address - Country:US
Practice Address - Phone:801-422-2145
Practice Address - Fax:406-422-0555
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6743304-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT2255A2300XMedicare ID - Type UnspecifiedATHLETIC TRAINER