Provider Demographics
NPI:1356863294
Name:PAYNE, DAVID TAYLOR IV (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:TAYLOR
Last Name:PAYNE
Suffix:IV
Gender:M
Credentials:LAT, ATC
Other - Prefix:MR
Other - First Name:DAVID
Other - Middle Name:TAYLOR
Other - Last Name:PAYNE
Other - Suffix:IV
Other - Last Name Type:Professional Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:105 BOB WHITE RD
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047-2513
Mailing Address - Country:US
Mailing Address - Phone:478-957-2535
Mailing Address - Fax:
Practice Address - Street 1:105 BOB WHITE RD
Practice Address - Street 2:
Practice Address - City:KATHLEEN
Practice Address - State:GA
Practice Address - Zip Code:31047
Practice Address - Country:US
Practice Address - Phone:478-957-2535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0030892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer