Healthcare Provider Details

I. General information

NPI: 1407072002
Provider Name (Legal Business Name): TODD KILLINGSWORTH AT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 W MAIN ST SUITE 14
DOTHAN AL
36305-1054
US

IV. Provider business mailing address

PO BOX 729
DOTHAN AL
36302-0729
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-2663
  • Fax: 334-836-2247
Mailing address:
  • Phone: 334-793-2663
  • Fax: 334-836-2247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number354
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: