MEDICARE: KYLE J BERRA ATC, LAT

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	573-039	WI

General Provider Information

NPI Number	:	1386833390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLE J BERRA ATC, LAT

Provider Business Mailing Address
First Line	:	P.O. BOX 338
Second Line	:
City	:	NORTH FREEDOM
State	:	WI
Zip	:	53951
Country	:	US
Telephone Number	:	608-522-4693
Fax Number	:

Provider Business Practice Location Address
First Line	:	333 E. SECOND ST
Second Line	:
City	:	RICHLAND CENTER
State	:	WI
Zip	:	53581
Country	:	US
Telephone Number	:	608-647-6321
Fax Number	:

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

Provider Enumeration Date	:	10/16/2007
Last Update Date	:	10/16/2007

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