Healthcare Provider Details

I. General information

NPI: 1851175152
Provider Name (Legal Business Name): TREVOR DALE OWENS ATHLETIC TRAINER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4136 SUMMERHILL RD
THOMASVILLE GA
31757-0148
US

IV. Provider business mailing address

4136 SUMMERHILL RD
THOMASVILLE GA
31757-0148
US

V. Phone/Fax

Practice location:
  • Phone: 229-977-1412
  • Fax:
Mailing address:
  • Phone: 229-977-1412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT04698
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: