Healthcare Provider Details

I. General information

NPI: 1669752648
Provider Name (Legal Business Name): ANDREW JACKSON GRUBBS JR. ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6262 VETERANS PKWY
COLUMBUS GA
31909-3540
US

IV. Provider business mailing address

6262 VETERANS PKWY
COLUMBUS GA
31909-3540
US

V. Phone/Fax

Practice location:
  • Phone: 706-494-3408
  • Fax:
Mailing address:
  • Phone: 706-494-3408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT000986
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: