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General NPI Number Information
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NPI Number | 1659164796
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Entity Type | Individual
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Provider Name | JUAN ANTONIO
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Gender | Male
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Dates
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Enumeration Date | 05/22/2025
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Last Update Date | 05/22/2025
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Provider Practice Location Address
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Address Line | 1021 CENTRAL AVE
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City | DEMOREST
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State | GA
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Zip | 30535-5252
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Country | US
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Telephone | 706-778-8500
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Fax |
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Provider Business Mailing Address
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Address Line | 3716 BOLDING CIR
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City | FLOWERY BRANCH
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State | GA
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Zip | 30542-3054
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Country | US
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Telephone | 770-561-3206
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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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