=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437628047
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADLEY BELCHER LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2018
-----------------------------------------------------
Last Update Date | 08/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1891 E 600 S
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46938-1536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-667-4096
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1891 E 600 S
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46938-1536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-667-4096
-----------------------------------------------------
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 | 36003359A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------