MEDICARE: MR. J R TITSWORTH ATC, LAT, LPTA

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		FL

General Provider Information

NPI Number	:	1861428120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. J R TITSWORTH ATC, LAT, LPTA

Provider Business Mailing Address
First Line	:	5007 BOBWHITE CT
Second Line	:
City	:	DADE CITY
State	:	FL
Zip	:	33523-8806
Country	:	US
Telephone Number	:	352-583-0659
Fax Number	:

Provider Business Practice Location Address
First Line	:	5007 BOBWHITE CT
Second Line	:	38652 SR 52 , PHS DADE CITY FL 33525
City	:	DADE CITY
State	:	FL
Zip	:	33523-8806
Country	:	US
Telephone Number	:	352-583-0659
Fax Number	:

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

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	07/08/2007

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