MEDICARE: MRS. ERIN KAY TABACZKA 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	965401	MI

General Provider Information

NPI Number	:	1437272325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ERIN KAY TABACZKA ATC

Provider Business Mailing Address
First Line	:	3737 PRATT LAKE AVE SE
Second Line	:
City	:	LOWELL
State	:	MI
Zip	:	49331-9307
Country	:	US
Telephone Number	:	616-897-0861
Fax Number	:

Provider Business Practice Location Address
First Line	:	3737 PRATT LAKE AVE SE
Second Line	:
City	:	LOWELL
State	:	MI
Zip	:	49331-9307
Country	:	US
Telephone Number	:	616-897-0861
Fax Number	:

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

Provider Enumeration Date	:	04/07/2007
Last Update Date	:	07/08/2007

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