Healthcare Provider Details

I. General information

NPI: 1962485300
Provider Name (Legal Business Name): TERRY TRUNDLE ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 CANTON RD NE
MARIETTA GA
30060-7276
US

IV. Provider business mailing address

2529 EDEN RIDGE LN
ACWORTH GA
30101-3026
US

V. Phone/Fax

Practice location:
  • Phone: 770-792-7522
  • Fax: 770-792-7508
Mailing address:
  • Phone: 770-792-7522
  • Fax: 770-792-7508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT000293
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: