MEDICARE: PHILIP ROGERS 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	AT1602	TX

General Provider Information

NPI Number	:	1376967828
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP ROGERS L.A.T.

Provider Business Mailing Address
First Line	:	9806 PALOMINO OAKS
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78254-5967
Country	:	US
Telephone Number	:	512-652-8218
Fax Number	:

Provider Business Practice Location Address
First Line	:	9806 PALOMINO OAKS
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78254-5967
Country	:	US
Telephone Number	:	512-652-8218
Fax Number	:

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

Provider Enumeration Date	:	02/04/2014
Last Update Date	:	02/04/2014

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