Healthcare Provider Details

I. General information

NPI: 1386639706
Provider Name (Legal Business Name): PAUL ANDREW CACOLICE A.T.,C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 PATTERSON HALL, EXERCISE AND REHAB SCIENCES SLIPPERY ROCK UNIVERSITY
SLIPPERY ROCK PA
16057
US

IV. Provider business mailing address

767 COTTONWOOD DR
MONROEVILLE PA
15146-1103
US

V. Phone/Fax

Practice location:
  • Phone: 724-738-4308
  • Fax:
Mailing address:
  • Phone: 860-841-3171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: