MEDICARE: MR. RAYMOND LESLIE BURNETT IV 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	AT003781	GA

General Provider Information

NPI Number	:	1942787023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RAYMOND LESLIE BURNETT IV ATC, LAT

Provider Business Mailing Address
First Line	:	3240 N E EXPY NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30341-4003
Country	:	US
Telephone Number	:	404-480-9330
Fax Number	:

Provider Business Practice Location Address
First Line	:	3240 NORTHEAST EXPY NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30341-4003
Country	:	US
Telephone Number	:	404-480-9330
Fax Number	:

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

Provider Enumeration Date	:	07/23/2018
Last Update Date	:	11/21/2021

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