Healthcare Provider Details

I. General information

NPI: 1225002728
Provider Name (Legal Business Name): BONNE ROSE MCGOWAN ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 W 5TH AVE
COLUMBUS OH
43212-2495
US

IV. Provider business mailing address

5691 SUNBURY RD
GAHANNA OH
43230-1147
US

V. Phone/Fax

Practice location:
  • Phone: 614-488-7929
  • Fax: 614-488-5792
Mailing address:
  • Phone: 614-471-9660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-00975
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: