Healthcare Provider Details

I. General information

NPI: 1083679583
Provider Name (Legal Business Name): WILLIAM ROGER CUBBAGE JR. ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 06/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 SHELBYVILLE RD
LOUISVILLE KY
40207-3122
US

IV. Provider business mailing address

2911 EXPLORER DR
LOUISVILLE KY
40218-4705
US

V. Phone/Fax

Practice location:
  • Phone: 502-736-2169
  • Fax: 717-412-9573
Mailing address:
  • Phone: 502-456-2529
  • Fax: 502-899-4175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT058
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: