Healthcare Provider Details

I. General information

NPI: 1043806375
Provider Name (Legal Business Name): AUSTIN ALLEN WESTLAND ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19131 SANDSTONE RD
BELLE FOURCHE SD
57717-6500
US

IV. Provider business mailing address

19131 SANDSTONE RD
BELLE FOURCHE SD
57717-6500
US

V. Phone/Fax

Practice location:
  • Phone: 605-210-1950
  • Fax:
Mailing address:
  • Phone: 605-210-1950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0630
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: