Healthcare Provider Details

I. General information

NPI: 1063173920
Provider Name (Legal Business Name): ERIC G WALDROP MOL, ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 MARSHALL AVE STE E
NEWPORT NEWS VA
23607-4636
US

IV. Provider business mailing address

117 LILLIE MARIE DR
PIEDMONT SC
29673-7673
US

V. Phone/Fax

Practice location:
  • Phone: 864-270-1219
  • Fax:
Mailing address:
  • Phone: 864-270-1219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.0002963
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: