Provider Demographics
NPI:1720507262
Name:AT DIRECT SPORTS MEDICINE, LLC
Entity type:Organization
Organization Name:AT DIRECT SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ATHLETIC TRAINER
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:AT
Authorized Official - Phone:520-235-0067
Mailing Address - Street 1:6424 E FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-6042
Mailing Address - Country:US
Mailing Address - Phone:520-235-0067
Mailing Address - Fax:
Practice Address - Street 1:6424 E FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-6042
Practice Address - Country:US
Practice Address - Phone:520-235-0067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13182083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Multi-Specialty