=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134659055
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRANT DUNCAN ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2017
-----------------------------------------------------
Last Update Date | 06/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4701 176TH AVE
-----------------------------------------------------
City | SHERRARD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61281-9603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-593-2175
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 VALLEY VIEW DR STE 200
-----------------------------------------------------
City | MOLINE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61265-6152
-----------------------------------------------------
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 | 085172
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 096.004383
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------