Healthcare Provider Details

I. General information

NPI: 1053391904
Provider Name (Legal Business Name): CHAD MICHAEL LIBBY A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 1ST AVE NE COE COLLEGE, EBY FIELDHOUSE
CEDAR RAPIDS IA
52402-5008
US

IV. Provider business mailing address

702 TIPPERARY RD
IOWA CITY IA
52246-2791
US

V. Phone/Fax

Practice location:
  • Phone: 319-399-8014
  • Fax:
Mailing address:
  • Phone: 319-337-2764
  • Fax: 319-399-8721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number00273
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: