=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528559531
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRANT WEBSTER ATC, OPA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2018
-----------------------------------------------------
Last Update Date | 12/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 MCGUIRE LN
-----------------------------------------------------
City | PELHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35124-3614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-587-8963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2320 WAKITA DR SE
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30060-5568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-587-8963
-----------------------------------------------------
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 | 2000031572
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------