Healthcare Provider Details

I. General information

NPI: 1144878448
Provider Name (Legal Business Name): JEFFREY BRYAN MULLINS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2019
Last Update Date: 08/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 N OCOEE ST
CLEVELAND TN
37311-4475
US

IV. Provider business mailing address

1511 20TH ST NW
CLEVELAND TN
37311-1522
US

V. Phone/Fax

Practice location:
  • Phone: 423-614-8462
  • Fax: 423-614-8438
Mailing address:
  • Phone: 423-364-0169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0000000593
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: