=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073925491
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGE POULIS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2014
-----------------------------------------------------
Last Update Date | 07/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 BLUE JAYS WAY SUITE 3200
-----------------------------------------------------
City | TORONTO
-----------------------------------------------------
State | ONTARIO
-----------------------------------------------------
Zip | M5V 1J1
-----------------------------------------------------
Country | CA
-----------------------------------------------------
Telephone | 416-341-1262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 SANDPINE CT E
-----------------------------------------------------
City | HOMOSASSA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34446-4821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 5000082
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------