Healthcare Provider Details

I. General information

NPI: 1730428699
Provider Name (Legal Business Name): ROGER JOHN CASEY JR. ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2013
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12280 228TH ST N
SCANDIA MN
55073-9467
US

IV. Provider business mailing address

12280 228TH ST N
SCANDIA MN
55073-9467
US

V. Phone/Fax

Practice location:
  • Phone: 651-399-8497
  • Fax:
Mailing address:
  • Phone: 651-399-8497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1109
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number304448
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: