MEDICARE: BERNARD JOSEPH LOUGH ATC, LAT

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	AT2804	TX
2	2255A2300X	Athletic Trainer	AT1289	OH

General Provider Information

NPI Number	:	1346206026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERNARD JOSEPH LOUGH ATC, LAT

Provider Business Mailing Address
First Line	:	4301 BROADWAY ST
Second Line	:	CPO 288
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-6318
Country	:	US
Telephone Number	:	210-283-6481
Fax Number	:

Provider Business Practice Location Address
First Line	:	4301 BROADWAY ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-6318
Country	:	US
Telephone Number	:	210-829-3834
Fax Number	:	210-841-7324

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

Provider Enumeration Date	:	04/21/2006
Last Update Date	:	01/21/2015

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