MEDICARE: DANIEL JOSEPH EDWARDS 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

General Provider Information

NPI Number	:	1194743187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL JOSEPH EDWARDS ATC

Provider Business Mailing Address
First Line	:	807 S MISSION CIR
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65809-1348
Country	:	US
Telephone Number	:	417-831-2122
Fax Number	:

Provider Business Practice Location Address
First Line	:	807 S MISSION CIR
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65809-1348
Country	:	US
Telephone Number	:	417-831-2122
Fax Number	:

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

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	07/08/2007

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