MEDICARE: CORRINNE ROSQUILLO 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

General Provider Information

NPI Number	:	1265811889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORRINNE ROSQUILLO ATC

Provider Business Mailing Address
First Line	:	2406 LAKE BRANDT PL
Second Line	:	APT N
City	:	GREENSBORO
State	:	NC
Zip	:	27455-2286
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2406 LAKE BRANDT PL
Second Line	:	APT N
City	:	GREENSBORO
State	:	NC
Zip	:	27455-2286
Country	:	US
Telephone Number	:	336-392-9121
Fax Number	:

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

Provider Enumeration Date	:	05/28/2015
Last Update Date	:	05/28/2015

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