Healthcare Provider Details

I. General information

NPI: 1255741674
Provider Name (Legal Business Name): TIMOTHY OBRIEN LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 3RD ST NE MAYVILLE STATE UIVERSITY
MAYVILLE ND
58257-1217
US

IV. Provider business mailing address

330 3RD ST NE MAYVILLE STATE UIVERSITY
MAYVILLE ND
58257-1217
US

V. Phone/Fax

Practice location:
  • Phone: 701-788-4844
  • Fax: 701-788-4840
Mailing address:
  • Phone: 701-788-4844
  • Fax: 701-788-4840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number103-92
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: