Healthcare Provider Details

I. General information

NPI: 1336513241
Provider Name (Legal Business Name): ANTHONY VIDALI LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2015
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 W COLLEGE AVE
INDEPENDENCE KS
67301-8556
US

IV. Provider business mailing address

1057 W COLLEGE AVE
INDEPENDENCE KS
67301-8556
US

V. Phone/Fax

Practice location:
  • Phone: 620-331-4100
  • Fax:
Mailing address:
  • Phone: 815-529-9064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number24-01265
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: