=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245288463
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT CARL DETWYLER ATC, LAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2006
-----------------------------------------------------
Last Update Date | 05/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 PATEWOOD DR STE 100
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29615-3593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-436-1837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4001 PELHAM RD APT 302
-----------------------------------------------------
City | GREER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29650-4352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-501-3291
-----------------------------------------------------
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 | AL386
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT1042
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------