Healthcare Provider Details

I. General information

NPI: 1023569050
Provider Name (Legal Business Name): ZACHARY FERRIS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 CHERRY BLOSSOM WAY
GEORGETOWN KY
40324-9564
US

IV. Provider business mailing address

1638 WYATT PKWY
LEXINGTON KY
40505-4031
US

V. Phone/Fax

Practice location:
  • Phone: 502-868-3854
  • Fax:
Mailing address:
  • Phone: 859-455-6801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT1060
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: