MEDICARE: MR. ALEX HEATH DIBBLEY A.T.C., L.A.T.

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	J00288	LA

General Provider Information

NPI Number	:	1245434711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALEX HEATH DIBBLEY A.T.C., L.A.T.

Provider Business Mailing Address
First Line	:	4181 HICKORY BRANCH RD
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70611-3502
Country	:	US
Telephone Number	:	337-855-4404
Fax Number	:

Provider Business Practice Location Address
First Line	:	PO BOX 91705
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70609-0001
Country	:	US
Telephone Number	:	337-477-0248
Fax Number	:	337-477-8964

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

Provider Enumeration Date	:	06/11/2007
Last Update Date	:	07/08/2007

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