=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699061259
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OA ASSOCIATED LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2011
-----------------------------------------------------
Last Update Date | 06/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4550 MEMORIAL DR MOC-1, SUITE G-100
-----------------------------------------------------
City | BELLEVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62226-5372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-236-2246
-----------------------------------------------------
Fax | 618-236-2315
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4550 MEMORIAL DR MOC-1, SUITE G-100
-----------------------------------------------------
City | BELLEVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62226-5372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-236-2246
-----------------------------------------------------
Fax | 618-236-2315
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ATHLETIC TRAINER
-----------------------------------------------------
Name | JASON DANIEL NOELDNER
-----------------------------------------------------
Credential | ATC,LAT
-----------------------------------------------------
Telephone | 618-236-2246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 096002594
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------