Healthcare Provider Details

I. General information

NPI: 1326123779
Provider Name (Legal Business Name): ZEBULON ROGERS AT-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1765 OLD WEST BROAD ST
ATHENS GA
30606-2853
US

IV. Provider business mailing address

1765 OLD WEST BROAD ST BLDG 2-200
ATHENS GA
30606-2887
US

V. Phone/Fax

Practice location:
  • Phone: 706-549-1663
  • Fax: 706-546-8792
Mailing address:
  • Phone: 706-549-1663
  • Fax: 706-546-8792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001121
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: