=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780347971
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS DIGAETANO ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2021
-----------------------------------------------------
Last Update Date | 10/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224B JOHNSON FERRY RD NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-3820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-300-6670
-----------------------------------------------------
Fax | 470-300-6671
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33900 HARPER AVE STE 104
-----------------------------------------------------
City | CLINTON TWP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48035-4258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-350-2644
-----------------------------------------------------
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 | AT000573
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------