Healthcare Provider Details

I. General information

NPI: 1255190849
Provider Name (Legal Business Name): THEREN SWINFORD III ATC, LMT, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TD SWINFORD III ATC, LMT, LAT

II. Dates (important events)

Enumeration Date: 03/15/2024
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 S MARCO WAY
SATELLITE BEACH FL
32937-3453
US

IV. Provider business mailing address

255 S MARCO WAY
SATELLITE BEACH FL
32937-3453
US

V. Phone/Fax

Practice location:
  • Phone: 202-302-9860
  • Fax:
Mailing address:
  • Phone: 202-302-9860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL2259
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: