=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730154923
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT JOSEPH SANDMANN M ED., ATC, LAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2006
-----------------------------------------------------
Last Update Date | 10/26/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4100 HERITAGE AVE
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-5714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-540-4477
-----------------------------------------------------
Fax | 817-510-0188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9012 DRY CREEK DR
-----------------------------------------------------
City | FT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-480-5417
-----------------------------------------------------
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 | AT1471
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------