Healthcare Provider Details

I. General information

NPI: 1467441626
Provider Name (Legal Business Name): JAMES MICHAEL PREVOST EDD, SCAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 T R HARRIS DR
SHELBY NC
28150-3487
US

IV. Provider business mailing address

224 T R HARRIS DR
SHELBY NC
28150-3487
US

V. Phone/Fax

Practice location:
  • Phone: 704-466-8820
  • Fax:
Mailing address:
  • Phone: 704-466-8820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number2462
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number2462
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2462
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number2462
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code246ZX2200X
TaxonomyOrthopedic Assistant
License Number2462
License Number StateSC
# 6
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2462
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: