=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386002525
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVAN CHANDRA L.A.T, A.T.C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2016
-----------------------------------------------------
Last Update Date | 02/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 69 SHORE RD
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01721-1927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-361-6318
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 69 SHORE RD
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01721-1927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-361-6318
-----------------------------------------------------
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 | 2771
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------