MEDICARE: MRS. EMILY ALDEN MERRILL LAT, 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	0947	NC

General Provider Information

NPI Number	:	1508934159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. EMILY ALDEN MERRILL LAT, ATC

Provider Business Mailing Address
First Line	:	14738 LIONS PRIDE CT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28273-3935
Country	:	US
Telephone Number	:	704-361-8184
Fax Number	:	980-343-3803

Provider Business Practice Location Address
First Line	:	4301 SANDY PORTER RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28273-3214
Country	:	US
Telephone Number	:	980-343-3800
Fax Number	:	980-343-3803

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

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	07/08/2007

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