Healthcare Provider Details

I. General information

NPI: 1386745008
Provider Name (Legal Business Name): THOMAS CHARLES SIMMONS L.A.T., A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 2ND ST SE MIDDLE GEORGIA COLLEGE
COCHRAN GA
31014-1564
US

IV. Provider business mailing address

PO BOX 502
COCHRAN GA
31014-0502
US

V. Phone/Fax

Practice location:
  • Phone: 478-934-3117
  • Fax: 478-934-3117
Mailing address:
  • Phone: 478-934-3117
  • Fax: 478-934-3117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001245
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: