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NPI Code Detail

MEDICARE: ELLEN LAVIN LAT, ATC

MEDICARE: ELLEN LAVIN LAT, 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
1390200000XStudent in an Organized Health Care Education/Training Program
22255A2300XAthletic Trainer

General Provider Information

NPI Number : 1275077059
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELLEN LAVIN LAT, ATC
Provider Business Mailing Address
First Line : 1 COLLEGE PARK DR
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63141-8660
Country : US
Telephone Number : 920-619-9466
Fax Number :
Provider Business Practice Location Address
First Line : 1 COLLEGE PARK DR
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63141-8660
Country : US
Telephone Number : 920-619-9466
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/13/2016
Last Update Date : 01/11/2024

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