Healthcare Provider Details

I. General information

NPI: 1205316205
Provider Name (Legal Business Name): TANNER URBAN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2018
Last Update Date: 08/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7449 E SUMMERSIDE PL
BEL AIRE KS
67226-7678
US

IV. Provider business mailing address

7449 E SUMMERSIDE PL
BEL AIRE KS
67226-7678
US

V. Phone/Fax

Practice location:
  • Phone: 620-655-7398
  • Fax:
Mailing address:
  • Phone: 620-655-7398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: