Healthcare Provider Details

I. General information

NPI: 1275883951
Provider Name (Legal Business Name): TIMOTHY HEATH BLACKMON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 NEWNAN CROSSING BYP SUITE 200
NEWNAN GA
30265-2323
US

IV. Provider business mailing address

900 CIRCLE 75 PKWY SE SUITE 1700
ATLANTA GA
30339-3035
US

V. Phone/Fax

Practice location:
  • Phone: 770-460-4747
  • Fax: 678-673-5102
Mailing address:
  • Phone: 770-953-6929
  • Fax: 770-953-6972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT002165
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: