Provider Demographics
NPI:1558887109
Name:TRAYLOR, JUSTIN (ATC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:TRAYLOR
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 1:1201 OLD HIGHWAY 49 S STE 2
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MS
Mailing Address - Zip Code:39218-9617
Mailing Address - Country:US
Mailing Address - Phone:769-233-8844
Mailing Address - Fax:
Practice Address - Street 1:1201 OLD HIGHWAY 49 S STE 2
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MS
Practice Address - Zip Code:39218-9617
Practice Address - Country:US
Practice Address - Phone:769-233-8844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20000068892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000006889OtherBOARD OF CERTIFICATION