MEDICARE: MR. EDMESTON ADOLPHUS WOODLEY II 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	AT0426	MS

General Provider Information

NPI Number	:	1518168236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EDMESTON ADOLPHUS WOODLEY II ATC, LAT

Provider Business Mailing Address
First Line	:	309 LAKE AVE
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81004-2329
Country	:	US
Telephone Number	:	719-924-0168
Fax Number	:

Provider Business Practice Location Address
First Line	:	118 COLLEGE DR # 5017
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39406-0001
Country	:	US
Telephone Number	:	601-266-6666
Fax Number	:

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

Provider Enumeration Date	:	05/30/2007
Last Update Date	:	07/08/2007

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