=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831616739
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZACHARY DAVID HOWELL LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2017
-----------------------------------------------------
Last Update Date | 08/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1095 BELT LINE RD STE 400
-----------------------------------------------------
City | COLLINSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62234-4489
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-477-8550
-----------------------------------------------------
Fax | 618-477-8551
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 704 LASALLE ST
-----------------------------------------------------
City | COLLINSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62234-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-973-8090
-----------------------------------------------------
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 | 2017025263
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 096004486
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------