Healthcare Provider Details

I. General information

NPI: 1811927635
Provider Name (Legal Business Name): LANCE CHARLES HUTCHINS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3708 NORTHSIDE DR
MACON GA
31210-2404
US

IV. Provider business mailing address

3708 NORTHSIDE DR
MACON GA
31210-2404
US

V. Phone/Fax

Practice location:
  • Phone: 478-745-4206
  • Fax:
Mailing address:
  • Phone: 478-745-4206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224L00000X
TaxonomyPedorthist
License NumberC50456
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT000130
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: