Healthcare Provider Details

I. General information

NPI: 1184681413
Provider Name (Legal Business Name): MARK E HILBURN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 RED DEVIL LN
RUSSELL KY
41169-1561
US

IV. Provider business mailing address

PO BOX 781
FLATWOODS KY
41139-0781
US

V. Phone/Fax

Practice location:
  • Phone: 606-836-9658
  • Fax: 606-836-9650
Mailing address:
  • Phone: 606-923-9848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT382
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: