Healthcare Provider Details

I. General information

NPI: 1073925491
Provider Name (Legal Business Name): GEORGE POULIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2014
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BLUE JAYS WAY SUITE 3200
TORONTO ONTARIO
M5V 1J1
CA

IV. Provider business mailing address

12 SANDPINE CT E
HOMOSASSA FL
34446-4821
US

V. Phone/Fax

Practice location:
  • Phone: 416-341-1262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number5000082
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: