Healthcare Provider Details

I. General information

NPI: 1174528103
Provider Name (Legal Business Name): ATHENS SPORTS MEDICINE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 PARK DR
GREENSBORO GA
30642-3465
US

IV. Provider business mailing address

4714 GETTYSBURG RD LEGAL DEPARTMENT
MECHANICSBURG PA
17055-4325
US

V. Phone/Fax

Practice location:
  • Phone: 706-453-1600
  • Fax: 706-453-4498
Mailing address:
  • Phone: 717-972-1100
  • Fax: 717-975-9981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MICAEL E. TARVIN
Title or Position: VICE PRESIDENT
Credential:
Phone: 717-972-1100