Healthcare Provider Details

I. General information

NPI: 1720248750
Provider Name (Legal Business Name): CASEY J ROBERTSON ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 07/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 N CEDAR ST
ROLLA MO
65401-3350
US

IV. Provider business mailing address

906 N CEDAR ST
ROLLA MO
65401-3350
US

V. Phone/Fax

Practice location:
  • Phone: 573-368-0999
  • Fax: 573-368-2777
Mailing address:
  • Phone: 573-368-0999
  • Fax: 573-368-2777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2004023926
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: