MEDICARE: KERRY ALAN CLEWELL 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	1736	AL

General Provider Information

NPI Number	:	1316481484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERRY ALAN CLEWELL ATC

Provider Business Mailing Address
First Line	:	1512 S US HIGHWAY 31
Second Line	:
City	:	BAY MINETTE
State	:	AL
Zip	:	36507-2611
Country	:	US
Telephone Number	:	251-580-3232
Fax Number	:

Provider Business Practice Location Address
First Line	:	1512 S US HIGHWAY 31
Second Line	:
City	:	BAY MINETTE
State	:	AL
Zip	:	36507-2611
Country	:	US
Telephone Number	:	251-580-3232
Fax Number	:

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

Provider Enumeration Date	:	12/08/2016
Last Update Date	:	12/08/2016

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