MEDICARE: CHARLOTTE KELSO EDS, LATC

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	AT002524	GA
2	2255A2300X	Athletic Trainer	0126000377	VA

General Provider Information

NPI Number	:	1396106886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLOTTE KELSO EDS, LATC

Provider Business Mailing Address
First Line	:	165 RIDGELAND WAY NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30305-4357
Country	:	US
Telephone Number	:	571-332-9630
Fax Number	:

Provider Business Practice Location Address
First Line	:	2383 N DRUID HILLS RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30329-3126
Country	:	US
Telephone Number	:	678-676-1059
Fax Number	:

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

Provider Enumeration Date	:	03/11/2016
Last Update Date	:	03/11/2016

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