Healthcare Provider Details

I. General information

NPI: 1083121917
Provider Name (Legal Business Name): BRENT ALEXANDER ROARK ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2017
Last Update Date: 12/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 VERMILLION ST
ATHENS WV
24712-9027
US

IV. Provider business mailing address

1000 VERMILLION ST
ATHENS WV
24712-9027
US

V. Phone/Fax

Practice location:
  • Phone: 304-384-6320
  • Fax: 304-384-5117
Mailing address:
  • Phone: 304-384-6320
  • Fax: 304-384-5117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001370
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: