MEDICARE: MR. TODD DELLNER SANDBERG MS, 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		WA

General Provider Information

NPI Number	:	1497810261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TODD DELLNER SANDBERG MS, ATC

Provider Business Mailing Address
First Line	:	6907 N OXFORD LN
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99208-3842
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 W HAWTHORNE RD
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99251-0001
Country	:	US
Telephone Number	:	509-777-3714
Fax Number	:

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

Provider Enumeration Date	:	12/22/2006
Last Update Date	:	07/08/2007

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