MEDICARE: LONNIE PERRY ROBERTS III

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AT10109	TX

General Provider Information

NPI Number	:	1043038409
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LONNIE PERRY ROBERTS III

Provider Business Mailing Address
First Line	:	1641 LAKE WATEREE DR
Second Line	:
City	:	FLORENCE
State	:	SC
Zip	:	29501-8153
Country	:	US
Telephone Number	:	843-731-4101
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 S GLASGOW DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-4518
Country	:	US
Telephone Number	:	843-731-4101
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2024
Last Update Date	:	01/21/2026

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