=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093456139
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAYME STEPHEN EARLE LAT, ATC, CSCS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2022
-----------------------------------------------------
Last Update Date | 04/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 398 BLUE JAY DR
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64068-1977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-407-2315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23201 NE 164TH ST
-----------------------------------------------------
City | KEARNEY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64060-9280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-560-8973
-----------------------------------------------------
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 | 2021036518
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------