Healthcare Provider Details

I. General information

NPI: 1831310721
Provider Name (Legal Business Name): BRANT DOUGLAS BERKSTRESSER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 HERTY DR HANNER FIELDHOUSE, GEORGIA SOUTHERN UNIVERSITY
STATESBORO GA
30460-0001
US

IV. Provider business mailing address

50 HERTY DR HANNER FIELDHOUSE, GEORGIA SOUTHERN UNIVERSITY
STATESBORO GA
30460-0001
US

V. Phone/Fax

Practice location:
  • Phone: 912-681-5053
  • Fax: 912-486-7690
Mailing address:
  • Phone: 912-681-5053
  • Fax: 912-486-7690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001397
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: