Healthcare Provider Details

I. General information

NPI: 1063070092
Provider Name (Legal Business Name): JOHN MICHAEL CHANDLER ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 1ST AVE NE
CEDAR RAPIDS IA
52402-5092
US

IV. Provider business mailing address

2307 SNAPDRAGON CIR SW
CEDAR RAPIDS IA
52404-2173
US

V. Phone/Fax

Practice location:
  • Phone: 319-329-1978
  • Fax:
Mailing address:
  • Phone: 319-329-1978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number00140
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: