Healthcare Provider Details

I. General information

NPI: 1871534180
Provider Name (Legal Business Name): NEIL K CARROLL ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BRICKHILL AVE SUITE 303
SOUTH PORTLAND ME
04106-1999
US

IV. Provider business mailing address

100 BRICKHILL AVE SUITE 303
SOUTH PORTLAND ME
04106-1999
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-0040
  • Fax: 207-774-6501
Mailing address:
  • Phone: 207-773-0040
  • Fax: 207-774-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT244
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: