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General NPI Number Information
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NPI Number | 1982838496
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Entity Type | Individual
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Provider Name | ROBERT MICHAEL SUPER LAT, COF
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Gender | Male
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Dates
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Enumeration Date | 05/12/2009
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Last Update Date | 04/27/2014
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Provider Practice Location Address
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Address Line | 1255 W 15TH ST STE 540
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City | PLANO
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State | TX
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Zip | 75075-7248
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Country | US
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Telephone | 410-845-3929
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Fax | 972-767-3728
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Provider Business Mailing Address
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Address Line | 5571 EASTON RD.
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City | PIPERSVILLE
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State | PA
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Zip | 18947
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Country | US
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Telephone | 410-845-3929
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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 | 225000000X
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Taxonomy Name | Orthotic Fitter
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License Number | OF000004
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | RT005787
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License Number State | PA
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