Provider Demographics
NPI:1063163202
Name:LANE, KARL (ATC)
Entity type:Individual
Prefix:
First Name:KARL
Middle Name:
Last Name:LANE
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 1:21 ORTHO LN
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2315
Mailing Address - Country:US
Mailing Address - Phone:770-654-4946
Mailing Address - Fax:
Practice Address - Street 1:8259 WICKER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-8878
Practice Address - Country:US
Practice Address - Phone:219-365-6554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0028992255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty