Healthcare Provider Details

I. General information

NPI: 1538092218
Provider Name (Legal Business Name): AUBREY MCCOY BAUCOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 RIVER RD
ATHENS GA
30602-1538
US

IV. Provider business mailing address

1614 RED BARN RD
LIBERTY SC
29657-9606
US

V. Phone/Fax

Practice location:
  • Phone: 706-542-4378
  • Fax:
Mailing address:
  • Phone: 843-693-8723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number390200000X
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: