=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154420164
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS WAYNE HOLTON M.S.S. A.T.,C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 83 WINDHAM ST
-----------------------------------------------------
City | WILLIMANTIC
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06226-2211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-465-5171
-----------------------------------------------------
Fax | 860-465-4696
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 77 DEER RUN RD
-----------------------------------------------------
City | WINDHAM
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06280-1535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-450-0893
-----------------------------------------------------
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 | 255A2300X
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------