MEDICARE: XENA RAS 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	AT00505	RI

General Provider Information

NPI Number	:	1326540485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	XENA RAS ATC

Provider Business Mailing Address
First Line	:	11 ARBUTUS TRL
Second Line	:
City	:	CHARLESTOWN
State	:	RI
Zip	:	02813-3403
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	730 KINGSTOWN RD # A14
Second Line	:
City	:	SOUTH KINGSTOWN
State	:	RI
Zip	:	02879-3011
Country	:	US
Telephone Number	:	401-284-3424
Fax Number	:

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

Provider Enumeration Date	:	03/05/2018
Last Update Date	:	05/03/2021

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