Provider Demographics
NPI:1699307959
Name:SPECIALTY ATHLETIC TRAINING
Entity type:Organization
Organization Name:SPECIALTY ATHLETIC TRAINING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKARD
Authorized Official - Suffix:
Authorized Official - Credentials:CSCS, CSPS
Authorized Official - Phone:503-863-0512
Mailing Address - Street 1:9208 NE HIGHWAY 99 STE 107-117
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-8986
Mailing Address - Country:US
Mailing Address - Phone:503-863-0512
Mailing Address - Fax:
Practice Address - Street 1:501 SE ELLSWORTH RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-5101
Practice Address - Country:US
Practice Address - Phone:503-863-0512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty