Healthcare Provider Details

I. General information

NPI: 1497877005
Provider Name (Legal Business Name): ERIC MICHAEL DRAKE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 W 78TH ST
EDINA MN
55439-2516
US

IV. Provider business mailing address

9734 SAINT ANDREWS DR
ELKO MN
55020-9630
US

V. Phone/Fax

Practice location:
  • Phone: 952-946-9777
  • Fax: 952-946-9888
Mailing address:
  • Phone: 651-357-5117
  • Fax: 952-946-9888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1921
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: