Healthcare Provider Details

I. General information

NPI: 1578565982
Provider Name (Legal Business Name): MARJORIE JEAN ALBOHM ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8450 NORTHWEST BLVD
INDIANAPOLIS IN
46278-1381
US

IV. Provider business mailing address

4159 LAKEWOOD TRL
CLAYTON IN
46118-9373
US

V. Phone/Fax

Practice location:
  • Phone: 317-802-2880
  • Fax: 317-802-2170
Mailing address:
  • Phone: 317-802-2880
  • Fax: 317-802-2170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000100A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: