MEDICARE: CARL DENVER DE GUZMAN

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		OH
2	390200000X	Student in an Organized Health Care Education/Training Program		OH

General Provider Information

NPI Number	:	1093297624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARL DENVER DE GUZMAN

Provider Business Mailing Address
First Line	:	1414 CAPTAINS BRG
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45458-5705
Country	:	US
Telephone Number	:	540-846-2081
Fax Number	:

Provider Business Practice Location Address
First Line	:	1414 CAPTAINS BRG
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45458-5705
Country	:	US
Telephone Number	:	540-846-2081
Fax Number	:

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

Provider Enumeration Date	:	08/30/2018
Last Update Date	:	08/30/2018

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Directions to “ CARL DENVER DE GUZMAN ” Practice Location

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