Healthcare Provider Details

I. General information

NPI: 1619005451
Provider Name (Legal Business Name): SCOTT TRUSTY ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 NW ASHTON DR
BLUE SPRINGS MO
64015-1769
US

IV. Provider business mailing address

1711 S OUTER BELT RD
OAK GROVE MO
64075-8397
US

V. Phone/Fax

Practice location:
  • Phone: 816-229-3459
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number00122
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: