Healthcare Provider Details

I. General information

NPI: 1689489965
Provider Name (Legal Business Name): AUSTIN CURTIS TALLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2025
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 WASHINGTON ST
JEFFERSON GA
30549-1018
US

IV. Provider business mailing address

562 VIRGINIA AVE
JEFFERSON GA
30549-7299
US

V. Phone/Fax

Practice location:
  • Phone: 478-973-8180
  • Fax:
Mailing address:
  • Phone: 478-973-8180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: