=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417332255
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENJAMIN KEMPER ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2015
-----------------------------------------------------
Last Update Date | 07/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1539 29TH AVE N
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56303-1319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-250-1592
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1539 29TH AVE N
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56303-1319
-----------------------------------------------------
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 | 2000021534
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------