=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164559977
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN EUGENE CREASEY ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 260 FORT SANDERS WEST BLVD STE 200
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37922-3355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-558-4418
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2763 SHERINGHAM DR
-----------------------------------------------------
City | POWELL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37849-4836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-947-5848
-----------------------------------------------------
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 | AT 0000000724
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------