Healthcare Provider Details

I. General information

NPI: 1124531066
Provider Name (Legal Business Name): BRANDON LYONS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 11/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 MERIDIAN ST NW
NORMAL AL
35762-7500
US

IV. Provider business mailing address

PO BOX 1597
NORMAL AL
35762-1597
US

V. Phone/Fax

Practice location:
  • Phone: 256-372-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2077
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: