Healthcare Provider Details

I. General information

NPI: 1609158559
Provider Name (Legal Business Name): JOHN CHARLES ROBERTS JR. MSED, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2011
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 VERMILLION ST CONCORD UNIVERSITY
ATHENS WV
24712-9027
US

IV. Provider business mailing address

PO BOX 1000 CONCORD UNIVERSITY
ATHENS WV
24712-1000
US

V. Phone/Fax

Practice location:
  • Phone: 304-384-6346
  • Fax: 304-384-5331
Mailing address:
  • Phone: 304-384-6346
  • Fax: 304-384-5331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126000376
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: