MEDICARE: GINA C LEE ATC, LAT

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	AT003167	GA

General Provider Information

NPI Number	:	1710528823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA C LEE ATC, LAT

Provider Business Mailing Address
First Line	:	332 JETTA LN
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30115-8614
Country	:	US
Telephone Number	:	678-787-7473
Fax Number	:

Provider Business Practice Location Address
First Line	:	332 JETTA LN
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30115-8614
Country	:	US
Telephone Number	:	678-787-7473
Fax Number	:

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

Provider Enumeration Date	:	10/01/2019
Last Update Date	:	10/01/2019

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