Healthcare Provider Details

I. General information

NPI: 1235359282
Provider Name (Legal Business Name): TIM WILLIAM PIKE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 MOBERLY BUILDING 521 LANCASTER AVE
RICHMOND KY
40475-0284
US

IV. Provider business mailing address

203 MOBERLY BUILDING 521 LANCASTER AVE
RICHMOND KY
40475-0284
US

V. Phone/Fax

Practice location:
  • Phone: 859-622-2147
  • Fax: 859-622-8857
Mailing address:
  • Phone: 859-622-2147
  • Fax: 859-622-8857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT566
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: