=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508499922
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TREVOR RIFFEY ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2020
-----------------------------------------------------
Last Update Date | 02/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14802 W WIGWAM BLVD
-----------------------------------------------------
City | GOODYEAR
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85395-8231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-204-9424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14109 N 83RD AVE APT 333
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85381-4779
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-204-9424
-----------------------------------------------------
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 | ATR-008974
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------