Healthcare Provider Details

I. General information

NPI: 1740752518
Provider Name (Legal Business Name): ROLLIN ROSS DEXTER ATHLETIC TRAINER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 08/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 NW CLEARWATER DR
BEND OR
97703-9469
US

IV. Provider business mailing address

2855 NW CLEARWATER DR
BEND OR
97703-9469
US

V. Phone/Fax

Practice location:
  • Phone: 541-280-5389
  • Fax: 541-355-4010
Mailing address:
  • Phone: 541-815-4422
  • Fax: 541-355-4010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-635
License Number StateID

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: