Healthcare Provider Details

I. General information

NPI: 1780672675
Provider Name (Legal Business Name): JASON WADE LEMLEY ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GEAR AVE SUITE 159
WEST BURLINGTON IA
52655-1691
US

IV. Provider business mailing address

704 N HAVEN DR
CARTHAGE IL
62321-1104
US

V. Phone/Fax

Practice location:
  • Phone: 319-752-4553
  • Fax:
Mailing address:
  • Phone: 217-357-3161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number00133
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: