MEDICARE: MR. TAO LEE LAND ATC,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	096001502	IL
2	2255A2300X	Athletic Trainer	AT.0001317	CO

General Provider Information

NPI Number	:	1114995503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TAO LEE LAND ATC,LAT

Provider Business Mailing Address
First Line	:	141 MOBY ARENA
Second Line	:	CSU ATHLETICS
City	:	FORT COLLINS
State	:	CO
Zip	:	80523-0120
Country	:	US
Telephone Number	:	970-889-1702
Fax Number	:	970-491-6167

Provider Business Practice Location Address
First Line	:	141 MOBY ARENA
Second Line	:	CSU ATHLETICS
City	:	FORT COLLINS
State	:	CO
Zip	:	80523-0120
Country	:	US
Telephone Number	:	970-889-1702
Fax Number	:	970-491-6167

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

Provider Enumeration Date	:	03/10/2006
Last Update Date	:	07/17/2015

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