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General NPI Number Information
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NPI Number | 1386005650
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Entity Type | Individual
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Provider Name | SETH TISDALE MS,ATC, LAT,CES
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Gender | Male
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Dates
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Enumeration Date | 03/15/2016
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Last Update Date | 03/15/2016
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Provider Practice Location Address
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Address Line | 421 N WOODLAND BLVD UNIT 8284
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City | DELAND
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State | FL
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Zip | 32723-8300
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Country | US
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Telephone | 386-822-7029
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Fax |
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Provider Business Mailing Address
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Address Line | 422 W NEW YORK AVE APT. D
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City | DELAND
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State | FL
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Zip | 32720-5349
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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 |
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License Number State |
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