Healthcare Provider Details

I. General information

NPI: 1245657477
Provider Name (Legal Business Name): PATRICK DEACHILLA MS, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2014
Last Update Date: 03/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 LOCH RAVEN BLVD RUSSELL MORGAN BUILDING SUITE 405
BALTIMORE MD
21239-2945
US

IV. Provider business mailing address

438 E CROSS ST
BALTIMORE MD
21230-4126
US

V. Phone/Fax

Practice location:
  • Phone: 443-444-4764
  • Fax:
Mailing address:
  • Phone: 717-515-5088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA0000409
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: