Healthcare Provider Details

I. General information

NPI: 1245608769
Provider Name (Legal Business Name): CHRISTOPHER WORRELL LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 12/07/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 ROLLING RD
WEST SPRINGFIELD VA
22152-1515
US

IV. Provider business mailing address

6100 ROLLING RD
SPRINGFIELD VA
22152-1515
US

V. Phone/Fax

Practice location:
  • Phone: 571-279-7919
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0506404
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126002473
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: