Healthcare Provider Details

I. General information

NPI: 1215021555
Provider Name (Legal Business Name): MARTHA SHORT ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 BLANDING BLVD SUITE 28
MIDDLEBURG FL
32068-5185
US

IV. Provider business mailing address

1011 ORANGEWOOD RD
JACKSONVILLE FL
32259-3160
US

V. Phone/Fax

Practice location:
  • Phone: 904-282-8640
  • Fax: 904-282-8696
Mailing address:
  • Phone: 904-287-4649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL1270
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: