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General NPI Number Information
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NPI Number | 1831602473
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Entity Type | Individual
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Provider Name | GEORGE EDWARD MCGOVERN IV ATC
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Gender | Male
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Dates
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Enumeration Date | 11/06/2017
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Last Update Date | 11/06/2017
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Provider Practice Location Address
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Address Line | 1 WILDCAT LN
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City | DESTREHAN
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State | LA
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Zip | 70047-4001
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Country | US
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Telephone | 601-433-3333
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Fax |
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Provider Business Mailing Address
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Address Line | 106 ARLINE CT
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City | MONTZ
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State | LA
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Zip | 70068-8978
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Country | US
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Telephone | 601-433-3333
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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 | ATH.20088
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License Number State | LA
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