MEDICARE: TILA AYTCH-HENDERSON ATC, LAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AT6222	TX

General Provider Information

NPI Number	:	1033575527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TILA AYTCH-HENDERSON ATC, LAT

Provider Business Mailing Address
First Line	:	1223 DEEP RIVER DR
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77469-6249
Country	:	US
Telephone Number	:	562-489-4600
Fax Number	:

Provider Business Practice Location Address
First Line	:	1223 DEEP RIVER DR
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77469-6249
Country	:	US
Telephone Number	:	562-489-4600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2016
Last Update Date	:	01/13/2016

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