Healthcare Provider Details

I. General information

NPI: 1154708477
Provider Name (Legal Business Name): KENDAL REPASS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17100 NAIL CREEK
POTEAU OK
74953
US

IV. Provider business mailing address

PO BOX 492
POTEAU OK
74953-0492
US

V. Phone/Fax

Practice location:
  • Phone: 918-721-3923
  • Fax:
Mailing address:
  • Phone: 918-721-3923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT480
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: