Healthcare Provider Details

I. General information

NPI: 1649806902
Provider Name (Legal Business Name): AJA CARTER ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 VILLA RIDGE PKWY
LAWRENCEVILLE GA
30044-2327
US

IV. Provider business mailing address

317 VILLA RIDGE PKWY
LAWRENCEVILLE GA
30044-2327
US

V. Phone/Fax

Practice location:
  • Phone: 516-695-5551
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT003778
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: