Healthcare Provider Details

I. General information

NPI: 1720167984
Provider Name (Legal Business Name): PAUL R MUSGROVE ATC/L, CSCS,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

IV. Provider business mailing address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

V. Phone/Fax

Practice location:
  • Phone: 931-920-4644
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT366
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number101
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: