Healthcare Provider Details

I. General information

NPI: 1760627327
Provider Name (Legal Business Name): ZACHARY C ROBERTS ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2008
Last Update Date: 12/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSU ATHLETIC TRAINING SERVICES 901 S. NATIONAL AVE.
SPRINGFIELD MO
65897-0001
US

IV. Provider business mailing address

820 E MONTCLAIR ST APT. #217
SPRINGFIELD MO
65807-7513
US

V. Phone/Fax

Practice location:
  • Phone: 417-836-5336
  • Fax:
Mailing address:
  • Phone: 573-579-8702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2008009715
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: