Healthcare Provider Details

I. General information

NPI: 1730625252
Provider Name (Legal Business Name): QUENTIN ROOSEVELT CAVE LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2017
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67530 US HIGHWAY 33
GOSHEN IN
46526-8552
US

IV. Provider business mailing address

1423 S STRONG AVE
ELKHART IN
46514-1919
US

V. Phone/Fax

Practice location:
  • Phone: 574-831-2184
  • Fax:
Mailing address:
  • Phone: 574-596-4958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36003170A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: