Healthcare Provider Details

I. General information

NPI: 1558755298
Provider Name (Legal Business Name): AUSTIN DODDS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 11/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 RICE RD
SILVER LAKE KS
66539-9682
US

IV. Provider business mailing address

625 REDWOOD DR
ROSSVILLE KS
66533-9782
US

V. Phone/Fax

Practice location:
  • Phone: 785-582-4956
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number24-01207
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: