Healthcare Provider Details

I. General information

NPI: 1457752115
Provider Name (Legal Business Name): LAMAR RICHARD INNES ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2014
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4190 W HIGHWAY 80
DOUGLAS AZ
85607-6100
US

IV. Provider business mailing address

4190 W HIGHWAY 80
DOUGLAS AZ
85607-6100
US

V. Phone/Fax

Practice location:
  • Phone: 520-417-4124
  • Fax: 520-417-4096
Mailing address:
  • Phone: 520-417-4124
  • Fax: 520-417-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1203
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: