MEDICARE: MR. GREGG D CRAIN A.T.C.

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	109857	MO

General Provider Information

NPI Number	:	1710070511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREGG D CRAIN A.T.C.

Provider Business Mailing Address
First Line	:	5228 S KINGSHIGHWAY BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-2923
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5228 S KINGSHIGHWAY BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-2923
Country	:	US
Telephone Number	:	636-343-3355
Fax Number	:

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

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	07/08/2007

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