Provider Demographics
NPI:1013315761
Name:TICE, DALTON (ATC, EMT, CFT)
Entity Type:Individual
Prefix:MR
First Name:DALTON
Middle Name:
Last Name:TICE
Suffix:
Gender:M
Credentials:ATC, EMT, CFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 GREEN TREE RD
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19606-3340
Mailing Address - Country:US
Mailing Address - Phone:610-914-6463
Mailing Address - Fax:
Practice Address - Street 1:4901 GREEN TREE RD
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19606-3340
Practice Address - Country:US
Practice Address - Phone:610-914-6463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0056942255A2300X
NH05982255A2300X
PA186907146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic