Healthcare Provider Details

I. General information

NPI: 1083081715
Provider Name (Legal Business Name): TAYLOR WITZEL LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 08/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 LAUREL STREET
DES MOINES IA
50314
US

IV. Provider business mailing address

1262 OFFICE PARK RD APARTMENT 5
WEST DES MOINES IA
50265-2494
US

V. Phone/Fax

Practice location:
  • Phone: 515-323-6485
  • Fax:
Mailing address:
  • Phone: 712-221-1870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number079137
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: