=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679381248
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 3 PHASE ENDURANCE TRAINING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2024
-----------------------------------------------------
Last Update Date | 12/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11154 ROAD 230
-----------------------------------------------------
City | CECIL
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45821-9309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-438-5026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11154 ROAD 230
-----------------------------------------------------
City | CECIL
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45821-9309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-438-5026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SETH BIDLACK
-----------------------------------------------------
Credential | OTR
-----------------------------------------------------
Telephone | 419-438-5026
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225XP0019X
-----------------------------------------------------
Taxonomy Name | Physical Rehabilitation Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------