MEDICARE: GREGORY DEROAN CATRETT 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		FL

General Provider Information

NPI Number	:	1891730446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY DEROAN CATRETT ATC

Provider Business Mailing Address
First Line	:	2049 SAN MARCOS DR SE
Second Line	:	#222
City	:	WINTER HAVEN
State	:	FL
Zip	:	33880-6607
Country	:	US
Telephone Number	:	863-514-5328
Fax Number	:

Provider Business Practice Location Address
First Line	:	13895 HWY 27
Second Line	:
City	:	LAKE WALES
State	:	FL
Zip	:	33859-2549
Country	:	US
Telephone Number	:	863-638-7257
Fax Number	:

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

Provider Enumeration Date	:	06/18/2006
Last Update Date	:	07/08/2007

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