=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043723786
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD STEPHAN LOWRY ATC, LAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2017
-----------------------------------------------------
Last Update Date | 11/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7400 OLD MAIN HL
-----------------------------------------------------
City | LOGAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84322-7400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-797-1850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1506 N 260 E
-----------------------------------------------------
City | NORTH LOGAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84341-7517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-931-7775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------