MEDICARE: WENDY M KIRBY LATC

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	767	MA

General Provider Information

NPI Number	:	1063548220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WENDY M KIRBY LATC

Provider Business Mailing Address
First Line	:	29 GREENFIELD RD
Second Line	:
City	:	WESTPORT
State	:	MA
Zip	:	02790-4807
Country	:	US
Telephone Number	:	508-999-8731
Fax Number	:

Provider Business Practice Location Address
First Line	:	285 OLD WESTPORT RD
Second Line	:
City	:	NORTH DARTMOUTH
State	:	MA
Zip	:	02747-2356
Country	:	US
Telephone Number	:	508-999-8731
Fax Number	:	508-999-8867

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

Provider Enumeration Date	:	02/24/2007
Last Update Date	:	07/08/2007

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