Healthcare Provider Details

I. General information

NPI: 1134535347
Provider Name (Legal Business Name): FRED SPALDING ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 VALLEY ST APT 4
MINOT ND
58701-4881
US

IV. Provider business mailing address

511 VALLEY ST APT 4
MINOT ND
58701-4881
US

V. Phone/Fax

Practice location:
  • Phone: 208-660-9002
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number510-13
License Number StateND

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: