Provider Demographics
NPI:1902260318
Name:MAYFIELD, MARK (ATC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:MAYFIELD
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 1:523 BROOKS WOOLSEY RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-7031
Mailing Address - Country:US
Mailing Address - Phone:678-877-6440
Mailing Address - Fax:
Practice Address - Street 1:611 HIGHWAY 74 S
Practice Address - Street 2:SUITE 720
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3081
Practice Address - Country:US
Practice Address - Phone:678-877-6440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0006082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer