=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801590815
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DALTON MEADOR ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2023
-----------------------------------------------------
Last Update Date | 12/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 LAKESHORE DR
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35229-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-726-2011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14099 MILLDALE RD
-----------------------------------------------------
City | BROOKWOOD
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35444-3122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-215-2265
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------