MEDICARE: MR. ROBERT S. CHARLES-LISCOMBE 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	0076	NC

General Provider Information

NPI Number	:	1104890037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT S. CHARLES-LISCOMBE ATC

Provider Business Mailing Address
First Line	:	6702 POPLAR GROVE TRL
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27410-8629
Country	:	US
Telephone Number	:	336-664-6248
Fax Number	:	336-217-7237

Provider Business Practice Location Address
First Line	:	815 W MARKET ST
Second Line	:	DIVISION OF KINESIOLOGY
City	:	GREENSBORO
State	:	NC
Zip	:	27401-1823
Country	:	US
Telephone Number	:	336-272-7102
Fax Number	:	336-217-7237

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

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	07/08/2007

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