Provider Demographics
NPI:1790898351
Name:BAZEMORE, WILLIAM PRESTON (ATC)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:PRESTON
Last Name:BAZEMORE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 GRANT LN
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-2958
Mailing Address - Country:US
Mailing Address - Phone:678-618-1209
Mailing Address - Fax:
Practice Address - Street 1:11320 WOODSTOCK RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-2548
Practice Address - Country:US
Practice Address - Phone:678-277-9083
Practice Address - Fax:678-277-9756
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0005482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer