=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639615578
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. BENNETT ALEXANDER PAGE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2017
-----------------------------------------------------
Last Update Date | 01/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1005 N BEECH DR
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37334-9422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-703-3411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1005 N BEECH DR
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37334-9422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-703-3411
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------