MEDICARE: PATRICIA KELLY BARE GROUNDS 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	LAT-2444	NC

General Provider Information

NPI Number	:	1194346965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA KELLY BARE GROUNDS ATC

Provider Business Mailing Address
First Line	:	445 TEXANNA WAY
Second Line	:
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-7351
Country	:	US
Telephone Number	:	850-582-2067
Fax Number	:

Provider Business Practice Location Address
First Line	:	445 TEXANNA WAY
Second Line	:
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-7351
Country	:	US
Telephone Number	:	850-582-2067
Fax Number	:

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

Provider Enumeration Date	:	05/02/2020
Last Update Date	:	05/02/2020

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