Provider Demographics
NPI:1174656581
Name:SWANSON, MYLES E (ATC, OTC)
Entity Type:Individual
Prefix:MR
First Name:MYLES
Middle Name:E
Last Name:SWANSON
Suffix:
Gender:M
Credentials:ATC, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30821
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31410-0821
Mailing Address - Country:US
Mailing Address - Phone:912-844-9982
Mailing Address - Fax:
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-8210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0002192255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer