Healthcare Provider Details

I. General information

NPI: 1831612092
Provider Name (Legal Business Name): SARA WEBER GROSS LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 07/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 RAIDER RD
OLIN NC
28660-9454
US

IV. Provider business mailing address

1838 BETHEL CHURCH RD
TAYLORSVILLE NC
28681-9084
US

V. Phone/Fax

Practice location:
  • Phone: 704-876-4191
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3002
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: