Healthcare Provider Details

I. General information

NPI: 1417129503
Provider Name (Legal Business Name): MICHAEL TROY OUELLETTE A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 03/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2351 HUDSON RD UNI-HUMAN PERFORMANCE CENTER
CEDAR FALLS IA
50614-0065
US

IV. Provider business mailing address

2351 HUDSON RD UNI-HUMAN PERFORMANCE CENTER
CEDAR FALLS IA
50614-0065
US

V. Phone/Fax

Practice location:
  • Phone: 319-415-7558
  • Fax: 319-273-2073
Mailing address:
  • Phone: 319-415-7558
  • Fax: 319-273-2073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number000642
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: