=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659022903
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | A'OUMONTYE ZOUWYILLE SUMRALL LAT, ATC, CES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2022
-----------------------------------------------------
Last Update Date | 01/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 805 SAGE BRUSH
-----------------------------------------------------
City | BELTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76513-3747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-414-8454
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2615 BUTTERFLY DR
-----------------------------------------------------
City | TEMPLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76502-7918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-414-8454
-----------------------------------------------------
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 | AT7698
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------