Healthcare Provider Details

I. General information

NPI: 1801216775
Provider Name (Legal Business Name): ROBERT ROOSA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2014
Last Update Date: 04/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1128 NE 2ND ST SUITE 201
CORVALLIS OR
97330-6230
US

IV. Provider business mailing address

1128 NE 2ND ST SUITE 201
CORVALLIS OR
97330-6230
US

V. Phone/Fax

Practice location:
  • Phone: 541-757-8100
  • Fax: 541-754-2707
Mailing address:
  • Phone: 541-757-8100
  • Fax: 541-754-2707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-AT-10151745
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: