Healthcare Provider Details

I. General information

NPI: 1215906367
Provider Name (Legal Business Name): MARCUS HOMER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 09/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 N 2260 W
HURRICANE UT
84737-2034
US

IV. Provider business mailing address

34 WEBB
LA VERKIN UT
84745-5309
US

V. Phone/Fax

Practice location:
  • Phone: 435-635-6480
  • Fax:
Mailing address:
  • Phone: 435-635-9742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096-002163
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number6651606-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: