=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922125905
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NEAL FREDERICK SAND ATC., CSCS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 PATRICK GYM SPEAR STREET
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05405-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-656-9573
-----------------------------------------------------
Fax | 802-656-9578
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 71 ALLEN DR
-----------------------------------------------------
City | MILTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05468-3872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-893-6724
-----------------------------------------------------
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 | 1040000068
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------