Healthcare Provider Details

I. General information

NPI: 1861480113
Provider Name (Legal Business Name): SCOTT EDWARD LEINBACH A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/11/2005
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

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

V. Phone/Fax

Practice location:
  • Phone: 319-752-4553
  • Fax: 319-752-7215
Mailing address:
  • Phone: 319-752-4553
  • Fax: 319-752-7215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number00190
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: