=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013325570
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER SPAUGH LAT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2014
-----------------------------------------------------
Last Update Date | 03/22/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 570 FORLINES RD
-----------------------------------------------------
City | WINTERVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28590-8512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-671-5786
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6430 DORAL DR
-----------------------------------------------------
City | TOBACCOVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27050-9557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-671-5786
-----------------------------------------------------
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 | 39240028
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------