Healthcare Provider Details

I. General information

NPI: 1740241520
Provider Name (Legal Business Name): TIMOTHY EMIL HANSEN A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BOBBY DODD WAY NW
ATLANTA GA
30332-0001
US

IV. Provider business mailing address

1109 PLEASANT OAKS CT
LAWRENCEVILLE GA
30044-7603
US

V. Phone/Fax

Practice location:
  • Phone: 404-894-2529
  • Fax:
Mailing address:
  • Phone: 404-894-2529
  • Fax: 404-894-0695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT000734
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: