=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760995815
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLER KRETSCHMAR ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2017
-----------------------------------------------------
Last Update Date | 11/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1150 DOUGLAS PIKE
-----------------------------------------------------
City | SMITHFIELD
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02917-1291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-232-6530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 DEER CREEK RUN
-----------------------------------------------------
City | SOMERSWORTH
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03878-1616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-817-4252
-----------------------------------------------------
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 | AT00449
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------