=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497148191
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IAN CHRISTOPHER STITES LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2015
-----------------------------------------------------
Last Update Date | 03/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | O&C BLDG M7 0355 MAIL CODE IHA 008
-----------------------------------------------------
City | KENNEDY SPACE CENTER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32899-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-867-8004
-----------------------------------------------------
Fax | 321-867-1144
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | O&C BLDG M7 0355 MAIL CODE IHA 008
-----------------------------------------------------
City | KENNEDY SPACE CENTER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32899-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-867-8004
-----------------------------------------------------
Fax | 321-867-1144
-----------------------------------------------------
=====================================================
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 | AL 2989
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------