Individual
TIM LEI
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
ATC
Contact information
Practice address
566 E 500 N, COLUMBIA CITY, IN 46725-7748
(260) 503-1599
Mailing address
566 E 500 N, COLUMBIA CITY, IN 46725-7748
(260) 503-1599
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
—
—
Other
Enumeration date
11/04/2015
Last updated
11/04/2015
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