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General NPI Number Information
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NPI Number | 1760051783
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Entity Type | Individual
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Provider Name | MEGUMI IKEDA MITCHELL MS, ATC/LAT
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Gender | Female
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Dates
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Enumeration Date | 06/23/2021
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Last Update Date | 06/23/2021
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Provider Practice Location Address
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Address Line | 21630 STATE HIGHWAY 59 S
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City | ROBERTSDALE
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State | AL
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Zip | 36567-6710
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Country | US
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Telephone | 251-947-4154
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Fax | 251-947-2666
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Provider Business Mailing Address
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Address Line | 14658 SILVER OAKS LOOP
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City | SILVERHILL
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State | AL
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Zip | 36576-3741
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Country | US
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Telephone | 251-600-9448
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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 | 1339
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License Number State | AL
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