MEDICARE: MS. DAISY MARIE KOVACH M.S., 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	:	1760405385
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DAISY MARIE KOVACH M.S., ATC

Provider Business Mailing Address
First Line	:	1141 BRIDFORD LAKE CIR APT P
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27407-5172
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	900 SPRING GARDEN ST
Second Line	:	136 HHP BUILDING, UNCG ATHLETICS
City	:	GREENSBORO
State	:	NC
Zip	:	27403-2410
Country	:	US
Telephone Number	:	336-334-5925
Fax Number	:	336-256-0407

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

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/08/2007

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