MEDICARE: MOLLIE COE AT

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	2601000371	MI

General Provider Information

NPI Number	:	1073988275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLIE COE AT

Provider Business Mailing Address
First Line	:	1185 HIDEAWAY VALLEY DR
Second Line	:	UNIT 12
City	:	HARBOR SPRINGS
State	:	MI
Zip	:	49740-8400
Country	:	US
Telephone Number	:	231-330-1412
Fax Number	:	231-238-2303

Provider Business Practice Location Address
First Line	:	1185 HIDEAWAY VALLEY DR
Second Line	:	UNIT 12
City	:	HARBOR SPRINGS
State	:	MI
Zip	:	49740-8400
Country	:	US
Telephone Number	:	231-330-1412
Fax Number	:	231-238-2303

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

Provider Enumeration Date	:	12/14/2015
Last Update Date	:	12/14/2015

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