Healthcare Provider Details

I. General information

NPI: 1407254451
Provider Name (Legal Business Name): MICHAEL JOHN CHESTERFIELD ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2014
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 WOOD ST
CLARION PA
16214-1240
US

IV. Provider business mailing address

840 WOOD ST
CLARION PA
16214-1240
US

V. Phone/Fax

Practice location:
  • Phone: 814-393-2006
  • Fax: 814-393-1735
Mailing address:
  • Phone: 814-393-2006
  • Fax: 814-393-1735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT004383
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierRT004383
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCOMMONWEALTH OF PA DEPT OF STATE BUREAU OF PROFESSIONAL AND OCCUPATIONAL AFFAIR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: