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General NPI Number Information
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NPI Number | 1831156785
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Entity Type | Individual
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Provider Name | ANTHONY CRAIG PORTWOOD MS, ATC, LAT
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Gender | Male
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Dates
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Enumeration Date | 04/26/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1151 W GRANADA BLVD
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City | ORMOND BEACH
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State | FL
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Zip | 32174-5912
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Country | US
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Telephone | 386-677-6455
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Fax | 386-677-6030
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Provider Business Mailing Address
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Address Line | 1023 CALLE GRANDE ST
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City | ORMOND BEACH
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State | FL
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Zip | 32174-7445
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Country | US
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Telephone | 386-677-4651
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Fax | 386-677-6030
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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 | AL421
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License Number State | FL
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