=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467822338
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KACEY HILDEBRAND ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2015
-----------------------------------------------------
Last Update Date | 10/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2828 1ST AVE STE 400
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25702-1236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-525-2690
-----------------------------------------------------
Fax | 304-529-6880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2828 1ST AVE STE 400
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25702-1236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-525-2690
-----------------------------------------------------
Fax | 304-529-6880
-----------------------------------------------------
=====================================================
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 | AT001253
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------