Healthcare Provider Details

I. General information

NPI: 1386290716
Provider Name (Legal Business Name): DAKOTA COOL ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 ORCHARD ROAD
DAVIS CA
95616
US

IV. Provider business mailing address

1900 BLUE OAKS BLVD APT 834
ROSEVILLE CA
95747-8445
US

V. Phone/Fax

Practice location:
  • Phone: 530-752-1730
  • Fax:
Mailing address:
  • Phone: 541-331-1987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: