Healthcare Provider Details

I. General information

NPI: 1215289186
Provider Name (Legal Business Name): KARI PAYTON LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3304 PARKSIDE AVE
LAKE STATION IN
46405-1143
US

IV. Provider business mailing address

480 AMHURST RD
VALPARAISO IN
46385-8029
US

V. Phone/Fax

Practice location:
  • Phone: 219-962-8531
  • Fax:
Mailing address:
  • Phone: 219-242-2105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36001821A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: