MEDICARE: LASHELLE DAVIS-IVERY 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	AT002844	GA

General Provider Information

NPI Number	:	1639535925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LASHELLE DAVIS-IVERY ATC

Provider Business Mailing Address
First Line	:	4570 SAINT MARYS RD
Second Line	:	APT G13
City	:	COLUMBUS
State	:	GA
Zip	:	31907-6566
Country	:	US
Telephone Number	:	330-338-6714
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 WIRE RD
Second Line	:
City	:	AUBURN
State	:	AL
Zip	:	36849-5419
Country	:	US
Telephone Number	:	330-338-6714
Fax Number	:

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

Provider Enumeration Date	:	01/04/2016
Last Update Date	:	05/31/2016

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