Healthcare Provider Details

I. General information

NPI: 1255853545
Provider Name (Legal Business Name): MARK MAHONEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13500 RIGGS WAY
WINDERMERE FL
34786-6324
US

IV. Provider business mailing address

13500 RIGGS WAY
WINDERMERE FL
34786-6324
US

V. Phone/Fax

Practice location:
  • Phone: 316-214-5542
  • Fax:
Mailing address:
  • Phone: 316-214-5542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: