Healthcare Provider Details

I. General information

NPI: 1104985480
Provider Name (Legal Business Name): WILLIAM THOMAS REGER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PIERMONT AVE TRAINING ROOM
HILLSDALE NJ
07642-1901
US

IV. Provider business mailing address

17 BROOKVIEW BLVD
CHESTNUT RIDGE NY
10977-6520
US

V. Phone/Fax

Practice location:
  • Phone: 201-358-7060
  • Fax:
Mailing address:
  • Phone: 845-641-8881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00116000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number000579-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: