Healthcare Provider Details

I. General information

NPI: 1326011834
Provider Name (Legal Business Name): BARE ESSENTIALS SPORTS MEDICINE COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 TRADITION TRL SUITE 207
HOLLY SPRINGS NC
27540-7045
US

IV. Provider business mailing address

445 TEXANNA WAY
HOLLY SPRINGS NC
27540-7351
US

V. Phone/Fax

Practice location:
  • Phone: 850-582-2067
  • Fax:
Mailing address:
  • Phone: 850-582-2067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL678
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT004435
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1443
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.0001047
License Number StateCO
# 5
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0506267
License Number StateNV
# 6
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-2444
License Number StateNC

VIII. Authorized Official

Name: MS. PATRICIA K BARE GROUNDS
Title or Position: OWNER & MEDICAL COORDINATOR
Credential: ATC/L, LAT
Phone: 850-582-2067