Healthcare Provider Details

I. General information

NPI: 1497108401
Provider Name (Legal Business Name): TAKAO IWANO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 12/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 MAGNOLIA ST
THOMASVILLE GA
31792-7236
US

IV. Provider business mailing address

1550 MAGNOLIA ST
THOMASVILLE GA
31792-7236
US

V. Phone/Fax

Practice location:
  • Phone: 660-864-6124
  • Fax:
Mailing address:
  • Phone: 660-864-6124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1956
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: