Healthcare Provider Details

I. General information

NPI: 1053977900
Provider Name (Legal Business Name): DANIEL ANTHONY LUDLOW LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 KNOLL NORTH DR STE 150
COLUMBIA MD
21045-2476
US

IV. Provider business mailing address

6913 DONACHIE RD APT D
BALTIMORE MD
21239-1109
US

V. Phone/Fax

Practice location:
  • Phone: 443-542-0062
  • Fax:
Mailing address:
  • Phone: 443-900-7294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA0001095
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: