Healthcare Provider Details

I. General information

NPI: 1881706307
Provider Name (Legal Business Name): DON S KOSHUTE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 TURNER MCCALL BLVD NW
ROME GA
30165-2545
US

IV. Provider business mailing address

PO BOX 949
ROME GA
30162-0949
US

V. Phone/Fax

Practice location:
  • Phone: 706-236-2758
  • Fax: 706-802-1408
Mailing address:
  • Phone: 706-236-2758
  • Fax: 706-802-1408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT000289
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: