=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942644059
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CALEB COUTURE ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2013
-----------------------------------------------------
Last Update Date | 04/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 76 LOU GROZA BLVD
-----------------------------------------------------
City | BEREA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44017-1238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-891-5124
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 80 EMERSON AVE APARTMENT:14002
-----------------------------------------------------
City | BEREA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44017-1171
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-755-1006
-----------------------------------------------------
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 | AT.004019
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------