Healthcare Provider Details

I. General information

NPI: 1669822508
Provider Name (Legal Business Name): DARYL MULLHOLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 6TH ST S
SAINT PETERSBURG FL
33701-4827
US

IV. Provider business mailing address

1009 WOODCREST AVE
CLEARWATER FL
33756-4670
US

V. Phone/Fax

Practice location:
  • Phone: 727-767-4257
  • Fax:
Mailing address:
  • Phone: 727-505-4776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL915
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: