Healthcare Provider Details

I. General information

NPI: 1467958058
Provider Name (Legal Business Name): MR. JAROD THOMAS DICKEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5285 UPPER MOUNTAIN RD
LOCKPORT NY
14094-1809
US

IV. Provider business mailing address

5285 UPPER MOUNTAIN RD
LOCKPORT NY
14094-1809
US

V. Phone/Fax

Practice location:
  • Phone: 716-359-4398
  • Fax:
Mailing address:
  • Phone: 716-359-4398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

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: