MEDICARE: GWYNETH SHORT 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	:	1316165954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWYNETH SHORT ATC

Provider Business Mailing Address
First Line	:	1519 S LEE ST
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80232-6342
Country	:	US
Telephone Number	:	303-988-9204
Fax Number	:

Provider Business Practice Location Address
First Line	:	1776 S JACKSON ST STE 616
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80210-3805
Country	:	US
Telephone Number	:	303-221-0162
Fax Number	:

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

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	07/08/2007

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