Provider Demographics
NPI:1124661517
Name:TREVOR TIPPETS DPM LLC
Entity type:Organization
Organization Name:TREVOR TIPPETS DPM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:W
Authorized Official - Last Name:TIPPETS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-588-8188
Mailing Address - Street 1:3474 LIBERTY RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4607
Mailing Address - Country:US
Mailing Address - Phone:503-588-8188
Mailing Address - Fax:503-588-8188
Practice Address - Street 1:3474 LIBERTY RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4607
Practice Address - Country:US
Practice Address - Phone:503-588-8188
Practice Address - Fax:503-588-8188
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TREVOR TIPPETS DPM LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty