MEDICARE: FAITH ALEXIS BOONE 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	102161	MO

General Provider Information

NPI Number	:	1093924516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FAITH ALEXIS BOONE ATC

Provider Business Mailing Address
First Line	:	4401 BEGG BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63121-3108
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4401 BEGG BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63121-3108
Country	:	US
Telephone Number	:	314-383-6733
Fax Number	:

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

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/08/2007

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