Healthcare Provider Details

I. General information

NPI: 1679980510
Provider Name (Legal Business Name): CARRIE EDER ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2014
Last Update Date: 07/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 UNIVERSITY AVE
WILLISTON ND
58801-4464
US

IV. Provider business mailing address

1410 UNIVERSITY AVE ATHLETIC DEPARTMENT
WILLISTON ND
58801-4464
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-4287
  • Fax:
Mailing address:
  • Phone: 701-580-2827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number483-12
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: