MEDICARE: KIM SMALL ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	25MT00187400	NJ

General Provider Information

NPI Number	:	1023421542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM SMALL ATC

Provider Business Mailing Address
First Line	:	404 INDIANA AVE
Second Line	:	ATHLETICS DEPARTMENT
City	:	LONG BRANCH
State	:	NJ
Zip	:	07740-6122
Country	:	US
Telephone Number	:	732-229-7300
Fax Number	:

Provider Business Practice Location Address
First Line	:	404 INDIANA AVE
Second Line	:	ATHLETICS DEPARTMENT
City	:	LONG BRANCH
State	:	NJ
Zip	:	07740-6122
Country	:	US
Telephone Number	:	732-229-7300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2014
Last Update Date	:	03/09/2015

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Directions to “ KIM SMALL ATC” Practice Location

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