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General NPI Number Information
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NPI Number | 1730423302
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Entity Type | Individual
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Provider Name | WADE D OLLIS ATC, LAT, CSCS
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Gender | Male
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Dates
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Enumeration Date | 11/20/2012
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Last Update Date | 11/20/2012
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Provider Practice Location Address
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Address Line | 426 S 4TH ST
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City | GADSDEN
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State | AL
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Zip | 35901-5259
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Country | US
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Telephone | 256-543-2981
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Fax |
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Provider Business Mailing Address
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Address Line | 60 VILLAGE TRACE DR
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City | SPRINGVILLE
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State | AL
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Zip | 35146-9001
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Country | US
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Telephone | 205-467-3339
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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 | 143
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License Number State | AL
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