MEDICARE: MR. JON ALMQUIST ATC

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	0126000155	VA

General Provider Information

NPI Number	:	1063442630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JON ALMQUIST ATC

Provider Business Mailing Address
First Line	:	10627 HUNTERS VALLEY RD
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22181-3019
Country	:	US
Telephone Number	:	703-255-7163
Fax Number	:	571-423-1267

Provider Business Practice Location Address
First Line	:	8115 GATEHOUSE RD
Second Line	:	SUITE 5100
City	:	FALLS CHURCH
State	:	VA
Zip	:	22042-1203
Country	:	US
Telephone Number	:	571-423-1264
Fax Number	:	571-423-1267

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

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	07/08/2007

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