MEDICARE: GLENN EDGERTON EDD, 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	1079	AZ

General Provider Information

NPI Number	:	1083149231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN EDGERTON EDD, LAT

Provider Business Mailing Address
First Line	:	PO BOX 15094
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86011-0543
Country	:	US
Telephone Number	:	928-523-6837
Fax Number	:

Provider Business Practice Location Address
First Line	:	1705 N SAN FRANCISCO ST
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-1348
Country	:	US
Telephone Number	:	928-523-6837
Fax Number	:

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

Provider Enumeration Date	:	04/25/2017
Last Update Date	:	04/25/2017

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