=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790171379
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASEY ELDER LAT,ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2015
-----------------------------------------------------
Last Update Date | 04/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 NORTH O'CONNOR
-----------------------------------------------------
City | IRVING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-600-6481
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2709 NEEDLES ST
-----------------------------------------------------
City | EULESS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76040-6386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-845-5514
-----------------------------------------------------
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 | AT5887
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------