=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376900308
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARTER GIANACAKOS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2016
-----------------------------------------------------
Last Update Date | 01/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4577 QUAIL CREEK TRCE N
-----------------------------------------------------
City | PITTSBORO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46167-8705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-788-3595
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4577 QUAIL CREEK TRCE N
-----------------------------------------------------
City | PITTSBORO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46167-8705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------