Healthcare Provider Details

I. General information

NPI: 1710418488
Provider Name (Legal Business Name): DALLAS FICHTNER LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2017
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 SAINT PAUL AVE
LINCOLN NE
68504-2760
US

IV. Provider business mailing address

5000 SAINT PAUL AVE
LINCOLN NE
68504-2760
US

V. Phone/Fax

Practice location:
  • Phone: 402-465-7545
  • Fax: 402-465-2170
Mailing address:
  • Phone: 402-465-7545
  • Fax: 402-465-2170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number447
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: