MEDICARE: YANNI JOSEPH THEODOSIOU

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	390200000X	Student in an Organized Health Care Education/Training Program	37147070	TX
2	2255A2300X	Athletic Trainer	37147070	TX

General Provider Information

NPI Number	:	1376000380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YANNI JOSEPH THEODOSIOU

Provider Business Mailing Address
First Line	:	4620 TILSON LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77041-9231
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 BOWERS BLVD
Second Line	:
City	:	HUNTSVILLE
State	:	TX
Zip	:	77341-0001
Country	:	US
Telephone Number	:	832-538-7223
Fax Number	:

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

Provider Enumeration Date	:	02/26/2019
Last Update Date	:	02/26/2019

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