Basic Information
| Provider Information | |||||||||
| NPI: | 1902281868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SKELTON | ||||||||
| FirstName: | GARRETT | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20240 REED LN | ||||||||
| Address2: | G-230 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977023374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613056837 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2200 NE NEFF RD | ||||||||
| Address2: | #200 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977014283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413823344 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2015 | ||||||||
| LastUpdateDate: | 07/21/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | AT-AT-10170878 | OR | Y | Other Service Providers | Specialist | 146N00000X | N | Emergency Medical Service Providers | Emergency Medical Technician, Basic |
No ID Information.