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General NPI Number Information
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NPI Number | 1396596482
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Entity Type | Individual
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Provider Name | LOREN NYDEGGER
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Gender | Male
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Dates
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Enumeration Date | 03/28/2024
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Last Update Date | 03/28/2024
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Provider Practice Location Address
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Address Line | 600 1ST ST SW
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City | MOUNT VERNON
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State | IA
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Zip | 52314-1098
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Country | US
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Telephone | 319-895-4573
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Fax |
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Provider Business Mailing Address
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Address Line | 204 OAK RIDGE DR SE
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City | MOUNT VERNON
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State | IA
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Zip | 52314-1585
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Country | US
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Telephone | 319-621-2602
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 000724
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License Number State | IA
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