=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548689342
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN NELSON LAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2014
-----------------------------------------------------
Last Update Date | 04/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2321 STOUT RD
-----------------------------------------------------
City | MENOMONIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54751-7003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-233-7740
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3807 ROBIN RD
-----------------------------------------------------
City | EAU CLAIRE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54703-0445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-456-9344
-----------------------------------------------------
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 | 1578-39
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------