Healthcare Provider Details

I. General information

NPI: 1427409200
Provider Name (Legal Business Name): ASHLEY BOUNDS ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 PINEWOOD DR.
MAGEE MS
39111
US

IV. Provider business mailing address

P.O. BOX 1053
MAGEE MS
39111
US

V. Phone/Fax

Practice location:
  • Phone: 601-748-3064
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0757
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: