Healthcare Provider Details

I. General information

NPI: 1285961565
Provider Name (Legal Business Name): ADAM RAIKES ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2009
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 OLD MAIN HL
LOGAN UT
84322-7000
US

IV. Provider business mailing address

7000 OLD MAIN HL
LOGAN UT
84322-7000
US

V. Phone/Fax

Practice location:
  • Phone: 520-271-9538
  • Fax: 520-271-9538
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number7415969-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: