Healthcare Provider Details

I. General information

NPI: 1235543026
Provider Name (Legal Business Name): RICK RAY A.T.,C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 FAIRLAWN AVE.
INSTITUTE WV
25112-1000
US

IV. Provider business mailing address

PO BOX 1000
INSTITUTE WV
25112-1000
US

V. Phone/Fax

Practice location:
  • Phone: 304-766-3225
  • Fax: 304-766-3364
Mailing address:
  • Phone: 304-766-3225
  • Fax: 304-766-3364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001195
License Number StateWV

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: