Healthcare Provider Details

I. General information

NPI: 1396669867
Provider Name (Legal Business Name): JEFFREY CHARLES LAKE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 NEWTON RD
IRMO SC
29063-2948
US

IV. Provider business mailing address

520 NEWTON RD
IRMO SC
29063-2948
US

V. Phone/Fax

Practice location:
  • Phone: 623-695-7705
  • Fax:
Mailing address:
  • Phone: 623-695-7705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATR1310ATH
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: