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General NPI Number Information
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NPI Number | 1972200681
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Entity Type | Individual
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Provider Name | MARK DONALD ULBRICHT LAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 02/13/2023
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Last Update Date | 02/13/2023
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Provider Practice Location Address
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Address Line | 1250 SISKIYOU BLVD
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City | ASHLAND
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State | OR
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Zip | 97520-5001
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Country | US
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Telephone | 541-552-6550
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Fax |
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Provider Business Mailing Address
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Address Line | 2630 W MAIN ST UNIT 11
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City | MEDFORD
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State | OR
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Zip | 97501-3697
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Country | US
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Telephone | 503-739-0550
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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 | AT-AT-10211957
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License Number State | OR
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