MEDICARE: LENA EVELYN DAVIS ATC, LAT, MS

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	AT002942	GA

General Provider Information

NPI Number	:	1164018552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LENA EVELYN DAVIS ATC, LAT, MS

Provider Business Mailing Address
First Line	:	5037 RIVER ROCK WAY
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30188-2994
Country	:	US
Telephone Number	:	770-789-0192
Fax Number	:

Provider Business Practice Location Address
First Line	:	5037 RIVER ROCK WAY
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30188-2994
Country	:	US
Telephone Number	:	770-789-0192
Fax Number	:

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

Provider Enumeration Date	:	12/19/2020
Last Update Date	:	12/19/2020

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