Provider Demographics
NPI:1699061259
Name:OA ASSOCIATED LLC
Entity type:Organization
Organization Name:OA ASSOCIATED LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ATHLETIC TRAINER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:NOELDNER
Authorized Official - Suffix:
Authorized Official - Credentials:ATC,LAT
Authorized Official - Phone:618-236-2246
Mailing Address - Street 1:4550 MEMORIAL DR
Mailing Address - Street 2:MOC-1, SUITE G-100
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5372
Mailing Address - Country:US
Mailing Address - Phone:618-236-2246
Mailing Address - Fax:618-236-2315
Practice Address - Street 1:4550 MEMORIAL DR
Practice Address - Street 2:MOC-1, SUITE G-100
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5372
Practice Address - Country:US
Practice Address - Phone:618-236-2246
Practice Address - Fax:618-236-2315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960025942255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty