Healthcare Provider Details

I. General information

NPI: 1326803024
Provider Name (Legal Business Name): JOHNNY TRAN MAT, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2024
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 E MAIN ST
CANTON GA
30114-2775
US

IV. Provider business mailing address

472 JOHN STEWART PL
SUWANEE GA
30024-2652
US

V. Phone/Fax

Practice location:
  • Phone: 404-938-7629
  • Fax:
Mailing address:
  • Phone: 678-756-7137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT004619
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: