MEDICARE: CASSIDY EIERS ATC, 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

General Provider Information

NPI Number	:	1811607203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASSIDY EIERS ATC, LAT

Provider Business Mailing Address
First Line	:	4200 N SEASONS VIEW DR APT A3005
Second Line	:
City	:	LEHI
State	:	UT
Zip	:	84043-6203
Country	:	US
Telephone Number	:	414-881-0179
Fax Number	:

Provider Business Practice Location Address
First Line	:	280 RIVER PARK DR STE 110
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-5765
Country	:	US
Telephone Number	:	414-881-0179
Fax Number	:

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

Provider Enumeration Date	:	11/28/2022
Last Update Date	:	11/28/2022

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