Healthcare Provider Details

I. General information

NPI: 1457863078
Provider Name (Legal Business Name): KELSEA RENE KOCAN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2017
Last Update Date: 11/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 LEXINGTON AVE
LEXINGTON KY
40506-0001
US

IV. Provider business mailing address

6209 SIEBERT ST
MIDLAND MI
48640-2723
US

V. Phone/Fax

Practice location:
  • Phone: 800-928-2287
  • Fax:
Mailing address:
  • Phone: 989-430-0272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT1381
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: