Healthcare Provider Details

I. General information

NPI: 1417015561
Provider Name (Legal Business Name): SHAWN CHRISTIAN GARLOCK ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17363 EDISON AVE
CHESTERFIELD MO
63005
US

IV. Provider business mailing address

13537 BARRETT PARKWAY DRIVE SUITE 105
BALLWIN MO
63021
US

V. Phone/Fax

Practice location:
  • Phone: 636-812-0094
  • Fax: 636-812-0152
Mailing address:
  • Phone: 314-821-9126
  • Fax: 314-821-9142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2001018584
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: