MEDICARE: MR. SCOTT HIROSHI TAKAO ATC; CSCS

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	0038	AZ
2	2255A2300X	Athletic Trainer	0844	NC
3	2255A2300X	Athletic Trainer		IL

General Provider Information

NPI Number	:	1720076425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SCOTT HIROSHI TAKAO ATC; CSCS

Provider Business Mailing Address
First Line	:	2637 E BIG VIEW DR
Second Line	:
City	:	ORO VALLEY
State	:	AZ
Zip	:	85755-1938
Country	:	US
Telephone Number	:	520-825-7963
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 E AJO WAY
Second Line	:	CHICAGO WHITE SOX
City	:	TUCSON
State	:	AZ
Zip	:	85713-6218
Country	:	US
Telephone Number	:	520-434-1263
Fax Number	:

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

Provider Enumeration Date	:	10/07/2005
Last Update Date	:	07/08/2007

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