=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780936732
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY ALAN COULTER MS, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2012
-----------------------------------------------------
Last Update Date | 01/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 COLLEGE ST
-----------------------------------------------------
City | NEWBERRY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29108-2126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-321-5184
-----------------------------------------------------
Fax | 800-882-9648
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 WALDEN HEIGHTS DR APT 513
-----------------------------------------------------
City | IRMO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29063-7865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-673-9498
-----------------------------------------------------
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 | 1398
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------