Healthcare Provider Details

I. General information

NPI: 1689637704
Provider Name (Legal Business Name): JASON MICHAEL GRAUS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 N BOULEVARD
RICHMOND VA
23230-4331
US

IV. Provider business mailing address

165 DURHAM ST SW
MARIETTA GA
30064-3203
US

V. Phone/Fax

Practice location:
  • Phone: 804-359-4444
  • Fax: 804-342-1275
Mailing address:
  • Phone: 678-594-0159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT000436
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: