Healthcare Provider Details

I. General information

NPI: 1205297272
Provider Name (Legal Business Name): MERCEDES INGRAM LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 03/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 HUFFS CHURCH ROAD
ALBURTIS PA
18011
US

IV. Provider business mailing address

833 HUFFS CHURCH ROAD
ALBURTIS PA
18011
US

V. Phone/Fax

Practice location:
  • Phone: 610-845-8767
  • Fax:
Mailing address:
  • Phone: 610-845-8767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT006113
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2000020722
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBOC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: