Healthcare Provider Details

I. General information

NPI: 1689249989
Provider Name (Legal Business Name): TORY ELIZABETH ENGEL LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2021
Last Update Date: 05/20/2021
Certification Date: 12/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 FALCON PKWY
FLOWERY BRANCH GA
30542-3176
US

IV. Provider business mailing address

6015 STATE BRIDGE RD APT 4307
DULUTH GA
30097-6488
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-3350
  • Fax:
Mailing address:
  • Phone: 908-442-3358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT003924
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT003924
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: