MEDICARE: MISS SALLY ANN MARKS MSED, ATL, ATC

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	0126000210	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0126000210	OTHER	VA	LICENSE TO PRACTICE

General Provider Information

NPI Number	:	1629196365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS SALLY ANN MARKS MSED, ATL, ATC

Provider Business Mailing Address
First Line	:	714 LAKE CAROLINE DRIVE
Second Line	:
City	:	RUTHER GLEN
State	:	VA
Zip	:	22546-5304
Country	:	US
Telephone Number	:	804-761-8688
Fax Number	:

Provider Business Practice Location Address
First Line	:	9414 ATLEE STATION ROAD
Second Line	:
City	:	MECHANICSVILLE
State	:	VA
Zip	:	23116-2600
Country	:	US
Telephone Number	:	804-723-2100
Fax Number	:

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

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	04/15/2017

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