MEDICARE: CIERRA CHANEL BOOTS 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

General Provider Information

NPI Number	:	1558808360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CIERRA CHANEL BOOTS MS, ATC

Provider Business Mailing Address
First Line	:	7820 SAN MARCOS RD
Second Line	:
City	:	ATASCADERO
State	:	CA
Zip	:	93422-4060
Country	:	US
Telephone Number	:	702-747-1807
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 HIGH SCHOOL HILL RD
Second Line	:
City	:	ATASCADERO
State	:	CA
Zip	:	93422-4189
Country	:	US
Telephone Number	:	805-550-7444
Fax Number	:

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

Provider Enumeration Date	:	01/31/2017
Last Update Date	:	01/31/2017

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