MEDICARE: MR. DARYL C WOOTEN A.T.C.

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	39	NM

General Provider Information

NPI Number	:	1316072317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DARYL C WOOTEN A.T.C.

Provider Business Mailing Address
First Line	:	2522 LOS ALAMOS CT
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-1657
Country	:	US
Telephone Number	:	505-522-4949
Fax Number	:	505-527-9767

Provider Business Practice Location Address
First Line	:	1755 EL PASEO RD
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-6011
Country	:	US
Telephone Number	:	505-527-9409
Fax Number	:	505-527-9767

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

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	07/08/2007

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