Healthcare Provider Details

I. General information

NPI: 1730002874
Provider Name (Legal Business Name): CLYDE MESSIAH III ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 N OCOEE ST
CLEVELAND TN
37311-4458
US

IV. Provider business mailing address

7917 SHALLOWMEADE LN
CHATTANOOGA TN
37421-1931
US

V. Phone/Fax

Practice location:
  • Phone: 423-614-8642
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2787
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: