Healthcare Provider Details

I. General information

NPI: 1447532478
Provider Name (Legal Business Name): PATRICK WILLIAM TALLEY MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 N BELLFLOWER BLVD SPORTS MEDICINE
LONG BEACH CA
90840-2039
US

IV. Provider business mailing address

1250 N BELLFLOWER BLVD SPORTS MEDICINE
LONG BEACH CA
90840-2039
US

V. Phone/Fax

Practice location:
  • Phone: 562-985-5881
  • Fax:
Mailing address:
  • Phone: 562-985-5881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: