=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275603177
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN ROXANE CARTER ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1424 W PACES FERRY RD NW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30327-2428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-367-5086
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1025 RIVERBEND CLUB DR SE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30339-2802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-988-8183
-----------------------------------------------------
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 | AT001208
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------