Healthcare Provider Details

I. General information

NPI: 1922144252
Provider Name (Legal Business Name): GUIDO VAN RYSSEGEM ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

OREGON STATE UNIVERSITY, STUDENT HEALTH, 201 PLAGEMAN
CORVALLIS OR
97331-5801
US

IV. Provider business mailing address

850 SW C AVE
CORVALLIS OR
97333-4315
US

V. Phone/Fax

Practice location:
  • Phone: 541-737-3106
  • Fax: 541-737-4530
Mailing address:
  • Phone: 541-737-3106
  • Fax: 541-737-4530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0821602328
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: