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General NPI Number Information
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NPI Number | 1104200179
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Entity Type | Individual
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Provider Name | PETER O'FALLON JR. ATC/LAT
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Gender | Male
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Dates
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Enumeration Date | 07/19/2015
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Last Update Date | 07/19/2015
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Provider Practice Location Address
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Address Line | 4421 COMMONS DR E SUITE-B 108
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City | DESTIN
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State | FL
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Zip | 32541-3484
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Country | US
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Telephone | 850-460-2588
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Fax |
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Provider Business Mailing Address
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Address Line | 93 DUNE LAKES CIR B106
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City | SANTA ROSA BEACH
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State | FL
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Zip | 32459-8393
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Country | US
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Telephone | 314-952-7123
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AL 4145
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License Number State | FL
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