Provider Demographics
NPI:1730785296
Name:RIEDEL, BRANDON TYLER (ATC)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:TYLER
Last Name:RIEDEL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 S COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-3366
Mailing Address - Country:US
Mailing Address - Phone:815-579-9454
Mailing Address - Fax:
Practice Address - Street 1:2219 SE 68TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-4026
Practice Address - Country:US
Practice Address - Phone:503-517-1063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL20000329882255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer