Healthcare Provider Details

I. General information

NPI: 1336299254
Provider Name (Legal Business Name): TRYG OLAF ODNEY ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 W. 18TH ST
SIOUX FALLS SD
57117-5039
US

IV. Provider business mailing address

6809 S AVALON CIR
SIOUX FALLS SD
57108-4000
US

V. Phone/Fax

Practice location:
  • Phone: 605-328-1727
  • Fax: 605-328-1857
Mailing address:
  • Phone: 605-366-2691
  • Fax: 605-328-1857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0092
License Number StateSD

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: