Provider Demographics
NPI:1053286906
Name:CARPENTER, MIKE
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20882 COVEY CT
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-5780
Mailing Address - Country:US
Mailing Address - Phone:541-420-3859
Mailing Address - Fax:
Practice Address - Street 1:20882 COVEY CT
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-5780
Practice Address - Country:US
Practice Address - Phone:541-420-3859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-09
Last Update Date:2025-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2471918-93172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty