MEDICARE: MRS. JUDI LYNN TEKAUTZ 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	1051	MN

General Provider Information

NPI Number	:	1063478907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JUDI LYNN TEKAUTZ ATC

Provider Business Mailing Address
First Line	:	111 RIVERFRONT
Second Line	:	SUITE 307
City	:	WINONA
State	:	MN
Zip	:	55987-3456
Country	:	US
Telephone Number	:	507-474-9300
Fax Number	:	507-474-9302

Provider Business Practice Location Address
First Line	:	111 RIVERFRONT
Second Line	:	SUITE 307
City	:	WINONA
State	:	MN
Zip	:	55987-3456
Country	:	US
Telephone Number	:	507-474-9300
Fax Number	:	507-474-9302

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

Provider Enumeration Date	:	04/20/2006
Last Update Date	:	05/27/2021

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