=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174063291
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAIME JAVIER PEREZ SR. ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2017
-----------------------------------------------------
Last Update Date | 03/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 NEW BRIDGE DR
-----------------------------------------------------
City | KYLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78640-5542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-665-0061
-----------------------------------------------------
Fax | 512-757-8041
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 NEW BRIDGE DR
-----------------------------------------------------
City | KYLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78640-5542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-665-0061
-----------------------------------------------------
Fax | 512-757-8041
-----------------------------------------------------
=====================================================
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 | AT2362
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------