Healthcare Provider Details

I. General information

NPI: 1508407966
Provider Name (Legal Business Name): RUSTY MIKOLAS ATP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9494 KIRBY DR
HOUSTON TX
77054-2521
US

IV. Provider business mailing address

5959 SHALLOWFORD RD STE 443
CHATTANOOGA TN
37421-2245
US

V. Phone/Fax

Practice location:
  • Phone: 713-791-9080
  • Fax: 713-791-9084
Mailing address:
  • Phone: 423-756-2268
  • Fax: 423-362-5413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247000000X
TaxonomyHealth Information Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: