Healthcare Provider Details

I. General information

NPI: 1558036772
Provider Name (Legal Business Name): DANIEL RAY MAPES ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 S LINDBERGH BLVD
SAINT LOUIS MO
63126-3236
US

IV. Provider business mailing address

573 COLONIAL DR
WOOD RIVER IL
62095-1881
US

V. Phone/Fax

Practice location:
  • Phone: 707-331-5733
  • Fax:
Mailing address:
  • Phone: 707-331-5733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: