MEDICARE: AIMEE M HOLLEY 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	AT 002504	OH

General Provider Information

NPI Number	:	1235384678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AIMEE M HOLLEY LAT, ATC

Provider Business Mailing Address
First Line	:	701 MCKINLEY DR
Second Line	:
City	:	BOWLING GREEN
State	:	OH
Zip	:	43402-1538
Country	:	US
Telephone Number	:	419-308-0108
Fax Number	:

Provider Business Practice Location Address
First Line	:	4025 INDIAN RD
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43606-2226
Country	:	US
Telephone Number	:	419-531-1693
Fax Number	:

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

Provider Enumeration Date	:	11/26/2008
Last Update Date	:	11/26/2008

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