MEDICARE: KAYLA A HUERTA LAT, 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	1721-39	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22	OTHER	WI	RESPIRATORY,REHABILITATIVE & RESTORATIVE SERVICE PROVIDER

General Provider Information

NPI Number	:	1407355498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLA A HUERTA LAT, ATC

Provider Business Mailing Address
First Line	:	700 W ROCK PLACE
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53209
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	285 FOREST GROVE DR STE 207
Second Line	:
City	:	PEWAUKEE
State	:	WI
Zip	:	53072-3738
Country	:	US
Telephone Number	:	877-732-2262
Fax Number	:

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

Provider Enumeration Date	:	02/06/2018
Last Update Date	:	02/06/2018

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