Provider Demographics
NPI:1801218821
Name:SOVINE, ZACHARY P (ATC, LAT)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:P
Last Name:SOVINE
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12845 TOUCHDOWN DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-7559
Mailing Address - Country:US
Mailing Address - Phone:260-224-7101
Mailing Address - Fax:
Practice Address - Street 1:12845 TOUCHDOWN DR
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-7559
Practice Address - Country:US
Practice Address - Phone:260-224-7101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002116A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN36002116AOtherATHLETIC TRAINER LICENSE