MEDICARE: TRISTAN RICHTER 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	390200000X	Student in an Organized Health Care Education/Training Program	AT002768	GA
2	390200000X	Student in an Organized Health Care Education/Training Program	1807	AL

General Provider Information

NPI Number	:	1902265937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRISTAN RICHTER ATC

Provider Business Mailing Address
First Line	:	300 E LONGLEAF DR
Second Line	:	APT 1218
City	:	AUBURN
State	:	AL
Zip	:	36832-1102
Country	:	US
Telephone Number	:	973-356-1695
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 WIRE RD
Second Line	:
City	:	AUBURN
State	:	AL
Zip	:	36849-5419
Country	:	US
Telephone Number	:	334-844-4000
Fax Number	:

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

Provider Enumeration Date	:	02/18/2016
Last Update Date	:	02/18/2016

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