Healthcare Provider Details

I. General information

NPI: 1699307959
Provider Name (Legal Business Name): SPECIALTY ATHLETIC TRAINING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 SE ELLSWORTH RD
VANCOUVER WA
98664-5101
US

IV. Provider business mailing address

9208 NE HIGHWAY 99 STE 107-117
VANCOUVER WA
98665-8986
US

V. Phone/Fax

Practice location:
  • Phone: 503-863-0512
  • Fax:
Mailing address:
  • Phone: 503-863-0512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name: RYAN LOCKARD
Title or Position: FOUNDER
Credential: CSCS, CSPS
Phone: 503-863-0512