=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134101876
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH EARL BAKER MS, ATC/R
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2005
-----------------------------------------------------
Last Update Date | 07/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2835 NE DESTINY DR
-----------------------------------------------------
City | MCMINNVILLE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97128-8885
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-476-4321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2835 NE DESTINY DR
-----------------------------------------------------
City | MCMINNVILLE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97128-8885
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-476-4321
-----------------------------------------------------
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 | AT-AT-746539
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------