MEDICARE: LARRY LOCKHART JR. PERSONAL TRAINER

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	174H00000X	Health Educator
2	133NN1002X	Nutrition Education Nutritionist
3	174400000X	Specialist
4	225XP0019X	Physical Rehabilitation Occupational Therapist
5	2255A2300X	Athletic Trainer	71212-826	GA
6	390200000X	Student in an Organized Health Care Education/Training Program
7	246Z00000X	Other Specialist/Technologist
8	103TE1100X	Exercise & Sports Psychologist

General Provider Information

NPI Number	:	1851691893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARRY LOCKHART JR. PERSONAL TRAINER

Provider Business Mailing Address
First Line	:	2511 LANTRAC CT
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30035-4006
Country	:	US
Telephone Number	:	678-281-1554
Fax Number	:	678-609-1484

Provider Business Practice Location Address
First Line	:	2511 LANTRAC CT
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30035-4006
Country	:	US
Telephone Number	:	678-281-1554
Fax Number	:	678-609-1484

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

Provider Enumeration Date	:	10/25/2010
Last Update Date	:	03/18/2013

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