=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013341577
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHLEY MARIE GRENZ MS, ATC, CA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2013
-----------------------------------------------------
Last Update Date | 03/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 MAIN ST N
-----------------------------------------------------
City | HERREID
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57632-2115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-437-2252
-----------------------------------------------------
Fax | 605-437-2508
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31406 117TH ST
-----------------------------------------------------
City | MOUND CITY
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57646-6402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-216-7411
-----------------------------------------------------
Fax | 605-437-2508
-----------------------------------------------------
=====================================================
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 | 0363
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------