Provider Demographics
NPI:1326011834
Name:BARE ESSENTIALS SPORTS MEDICINE COMPANY
Entity Type:Organization
Organization Name:BARE ESSENTIALS SPORTS MEDICINE COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & MEDICAL COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BARE GROUNDS
Authorized Official - Suffix:
Authorized Official - Credentials:ATC/L, LAT
Authorized Official - Phone:850-582-2067
Mailing Address - Street 1:445 TEXANNA WAY
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-7351
Mailing Address - Country:US
Mailing Address - Phone:850-582-2067
Mailing Address - Fax:
Practice Address - Street 1:171 TRADITION TRL
Practice Address - Street 2:SUITE 207
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540-7045
Practice Address - Country:US
Practice Address - Phone:850-582-2067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL6782255A2300X
PART0044352255A2300X
NCLAT-24442255A2300X
SC14432255A2300X
COAT.00010472255A2300X
NV05062672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV0506267OtherNEVADA ATHLETIC TRAINER'S LICENSE
PART004435OtherPENNSYLVANIA ATHLETIC TRAINER'S LICENSE
CO1047OtherCOLORADO STATE ATHLETIC TRAINER'S LICENSE
FLAL678OtherFLORIDA ATHLETIC TRAINER'S LICENSE
SC1443OtherSOUTH CAROLINA ATHLETIC TRAINER'S LICENSE
NCLAT-2444OtherNORTH CAROLINA BOARD OF ATHLETIC TRAINER EXAMINERS