Healthcare Provider Details

I. General information

NPI: 1588768022
Provider Name (Legal Business Name): CHAD RYAN DYBDAHL A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 INDIAN TRAIL LILBURN RD
NORCROSS GA
30093-2614
US

IV. Provider business mailing address

368 W WIND DR SW
LILBURN GA
30047-6429
US

V. Phone/Fax

Practice location:
  • Phone: 770-243-2000
  • Fax:
Mailing address:
  • Phone: 770-717-8867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT000532
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: