Healthcare Provider Details

I. General information

NPI: 1245647635
Provider Name (Legal Business Name): ADAM DOUGLAS HENRY ATC, SCAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

12890 COUNTY LINE RD ANDREWS HIGH SCHOOL
ANDREWS SC
29510-6877
US

IV. Provider business mailing address

12890 COUNTY LINE RD ANDREWS HIGH SCHOOL
ANDREWS SC
29510-6877
US

V. Phone/Fax

Practice location:
  • Phone: 843-264-3414
  • Fax:
Mailing address:
  • Phone: 843-264-3414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number869
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: