=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376085829
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS MCCALL LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2016
-----------------------------------------------------
Last Update Date | 11/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3200 WESTOWN PKWY
-----------------------------------------------------
City | WEST DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50266-1110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-858-6425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19858 HIGHWAY S45
-----------------------------------------------------
City | IOWA FALLS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50126-8637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 080473
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------