MEDICARE: MR. M. KELLY CRUISE 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	000522	OH

General Provider Information

NPI Number	:	1225479264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. M. KELLY CRUISE ATC

Provider Business Mailing Address
First Line	:	2572 E TOLBERT RD
Second Line	:
City	:	WOOSTER
State	:	OH
Zip	:	44691-9417
Country	:	US
Telephone Number	:	330-202-9035
Fax Number	:

Provider Business Practice Location Address
First Line	:	3205 SHREVE RD
Second Line	:
City	:	WOOSTER
State	:	OH
Zip	:	44691-4439
Country	:	US
Telephone Number	:	330-264-2114
Fax Number	:

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

Provider Enumeration Date	:	07/06/2013
Last Update Date	:	07/06/2013

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