MEDICARE: CORTNEY ALES 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	096004945	IL

General Provider Information

NPI Number	:	1306403084
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORTNEY ALES ATC

Provider Business Mailing Address
First Line	:	2338 COUNTY ROAD 1350 N
Second Line	:
City	:	EL PASO
State	:	IL
Zip	:	61738-9269
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2338 COUNTY ROAD 1350 N
Second Line	:
City	:	EL PASO
State	:	IL
Zip	:	61738-9269
Country	:	US
Telephone Number	:	209-923-3561
Fax Number	:

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

Provider Enumeration Date	:	05/28/2019
Last Update Date	:	12/30/2019

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