Healthcare Provider Details

I. General information

NPI: 1639138241
Provider Name (Legal Business Name): RAY GENE BELANGER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 FRAWLEY RD APARTMENT 815
EAST RIDGE TN
37412-4075
US

IV. Provider business mailing address

728 FRAWLEY RD APARTMENT 815
EAST RIDGE TN
37412-4075
US

V. Phone/Fax

Practice location:
  • Phone: 423-304-7953
  • Fax:
Mailing address:
  • Phone: 423-304-7953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number770
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: