MEDICARE: MISS STACY L VITEK ATC/CPT

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	0126000956	VA

General Provider Information

NPI Number	:	1063488328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS STACY L VITEK ATC/CPT

Provider Business Mailing Address
First Line	:	305 DOCK CT
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23435-2779
Country	:	US
Telephone Number	:	757-483-0144
Fax Number	:

Provider Business Practice Location Address
First Line	:	2007 MEADE PKWY
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23434-4259
Country	:	US
Telephone Number	:	757-539-6300
Fax Number	:	757-539-0704

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

Provider Enumeration Date	:	02/27/2006
Last Update Date	:	07/08/2007

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