Provider Demographics
NPI:1972200681
Name:ULBRICHT, MARK DONALD (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DONALD
Last Name:ULBRICHT
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 W MAIN ST UNIT 11
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-3697
Mailing Address - Country:US
Mailing Address - Phone:503-739-0550
Mailing Address - Fax:
Practice Address - Street 1:1250 SISKIYOU BLVD
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-5001
Practice Address - Country:US
Practice Address - Phone:541-552-6550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT-AT-102119572255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer