Healthcare Provider Details

I. General information

NPI: 1174662605
Provider Name (Legal Business Name): MULTI SPORT ORTHOTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 NORTHEAST EXPY NE BLDG 8, SUITE B
ATLANTA GA
30341-3932
US

IV. Provider business mailing address

3300 NORTHEAST EXPY NE BLDG 8, SUITE B
ATLANTA GA
30341-3932
US

V. Phone/Fax

Practice location:
  • Phone: 770-500-3996
  • Fax:
Mailing address:
  • Phone: 770-500-3996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number3712
License Number StateGA

VIII. Authorized Official

Name: JAMES FOX
Title or Position: PRESIDENT
Credential: CO, ATC
Phone: 770-500-3996