MEDICARE: REBEKAH BETH ERGLE MS, LAT, 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	AL5390	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2000028592	OTHER		NATA BOC
2	AL5390	OTHER	FL	STATE OF FLORIDA ATHLETIC TRAINING LICENSE

General Provider Information

NPI Number	:	1104343367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBEKAH BETH ERGLE MS, LAT, ATC

Provider Business Mailing Address
First Line	:	3209 VIRGINIA AVE
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34981-5596
Country	:	US
Telephone Number	:	772-462-7895
Fax Number	:

Provider Business Practice Location Address
First Line	:	3209 VIRGINIA AVE
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34981-5596
Country	:	US
Telephone Number	:	772-462-7895
Fax Number	:

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

Provider Enumeration Date	:	08/28/2017
Last Update Date	:	01/13/2020

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