MEDICARE: GRANT DUNCAN 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	085172	IA
2	2255A2300X	Athletic Trainer	096.004383	IL

General Provider Information

NPI Number	:	1134659055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRANT DUNCAN ATC

Provider Business Mailing Address
First Line	:	520 VALLEY VIEW DR STE 200
Second Line	:
City	:	MOLINE
State	:	IL
Zip	:	61265-6152
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4701 176TH AVE
Second Line	:
City	:	SHERRARD
State	:	IL
Zip	:	61281-9603
Country	:	US
Telephone Number	:	309-593-2175
Fax Number	:

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

Provider Enumeration Date	:	06/13/2017
Last Update Date	:	06/13/2017

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