MEDICARE: CHRISTOPHER IBACH MS, LAT, 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	240-00992	KS

General Provider Information

NPI Number	:	1033879184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTOPHER IBACH MS, LAT, ATC

Provider Business Mailing Address
First Line	:	300 E 27TH ST
Second Line	:
City	:	NORTH NEWTON
State	:	KS
Zip	:	67117-8061
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 E 27TH ST
Second Line	:
City	:	NORTH NEWTON
State	:	KS
Zip	:	67117-8061
Country	:	US
Telephone Number	:	316-284-5209
Fax Number	:

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

Provider Enumeration Date	:	12/29/2021
Last Update Date	:	12/29/2021

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