Healthcare Provider Details

I. General information

NPI: 1023568797
Provider Name (Legal Business Name): CLAIRE BONNORONT LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 08/08/2020
Certification Date: 08/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 STANLEY AVE
GREENWOOD SC
29649-2099
US

IV. Provider business mailing address

125 EDINBOROUGH CIR APT 4
GREENWOOD SC
29649-1339
US

V. Phone/Fax

Practice location:
  • Phone: 937-658-2212
  • Fax:
Mailing address:
  • Phone: 937-658-2212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberSC529906
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: