=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982092169
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN ANNE BRUECK ATC, LAT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2014
-----------------------------------------------------
Last Update Date | 12/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1218 WALTON LN SE
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30082-3873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-536-2730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1218 WALTON LN SE
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30082-3873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-536-2730
-----------------------------------------------------
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 | AT002284
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------