MEDICARE: MR. ARTHUR JOHN GABRIEL 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	36001651A	IN

General Provider Information

NPI Number	:	1518260827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ARTHUR JOHN GABRIEL LAT

Provider Business Mailing Address
First Line	:	138 N. LUCRETIA STREET
Second Line	:	JOHNSON CENTER
City	:	OAKLAND CITY
State	:	IN
Zip	:	47660
Country	:	US
Telephone Number	:	812-746-1262
Fax Number	:	812-746-1262

Provider Business Practice Location Address
First Line	:	138 N LUCRETIA ST
Second Line	:	JOHNSON CENTER
City	:	OAKLAND CITY
State	:	IN
Zip	:	47660-1038
Country	:	US
Telephone Number	:	812-746-1262
Fax Number	:	812-746-1262

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

Provider Enumeration Date	:	12/08/2010
Last Update Date	:	12/08/2010

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