Healthcare Provider Details

I. General information

NPI: 1184612756
Provider Name (Legal Business Name): JEFFREY PHILIP WEEMS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 FOX RIDGE RD
DOUGLAS GA
31535-5628
US

IV. Provider business mailing address

178 FOX RIDGE RD
DOUGLAS GA
31535-5628
US

V. Phone/Fax

Practice location:
  • Phone: 912-384-3172
  • Fax:
Mailing address:
  • Phone: 912-384-3172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number581
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: