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General NPI Number Information
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NPI Number | 1245703529
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Entity Type | Individual
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Provider Name | TERRIS DIOR HIGHTOWER LAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 01/09/2019
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Last Update Date | 01/09/2019
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Provider Practice Location Address
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Address Line | 4400 UNIVERSITY DR
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City | FAIRFAX
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State | VA
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Zip | 22030-4444
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Country | US
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Telephone | 850-791-8060
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Fax |
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Provider Business Mailing Address
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Address Line | 10495 BUTTERFIELD ST APT 32
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City | MANASSAS
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State | VA
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Zip | 20109-6848
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Country | US
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Telephone |
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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 | 0126003045
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License Number State | VA
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