=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003269267
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN RUBLE MS, LAT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2016
-----------------------------------------------------
Last Update Date | 07/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 FM 830 RD
-----------------------------------------------------
City | WILLIS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77378-5625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-856-1269
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 WESTVIEW BLVD APT 313
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77304-1929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT5657
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------