=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902342165
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK GREEN LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2017
-----------------------------------------------------
Last Update Date | 01/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 339 NACOOCHEE DR
-----------------------------------------------------
City | RABUN GAP
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30568-2200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-746-7725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19 COWEETA TER
-----------------------------------------------------
City | OTTO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28763-8141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-371-1010
-----------------------------------------------------
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 | AT002250
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------