Healthcare Provider Details

I. General information

NPI: 1487630034
Provider Name (Legal Business Name): JASON TREVOR ROBERTS ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ELYSIAN PARK AVE
LOS ANGELES CA
90012-1112
US

IV. Provider business mailing address

509 STATE ST
SCRANTON IA
51462-8418
US

V. Phone/Fax

Practice location:
  • Phone: 323-224-1500
  • Fax:
Mailing address:
  • Phone: 772-559-5703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL 1543
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: