MEDICARE: MR. KENNETH SEAN WILLEFORD 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	AT3465	TX

General Provider Information

NPI Number	:	1376637223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH SEAN WILLEFORD ATC, LAT

Provider Business Mailing Address
First Line	:	TCU BOX 297730
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76129
Country	:	US
Telephone Number	:	817-257-6737
Fax Number	:	817-257-7702

Provider Business Practice Location Address
First Line	:	3005 STADIUM DRIVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109
Country	:	US
Telephone Number	:	817-257-6737
Fax Number	:	817-257-7702

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/08/2007

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