MEDICARE: KYLE COSTANTINI ATC, LAT, MAT

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	AT.0002390	CO

General Provider Information

NPI Number	:	1417653742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLE COSTANTINI ATC, LAT, MAT

Provider Business Mailing Address
First Line	:	8000 UPTOWN AVE APT B3013
Second Line	:
City	:	BROOMFIELD
State	:	CO
Zip	:	80021-4795
Country	:	US
Telephone Number	:	321-332-2972
Fax Number	:

Provider Business Practice Location Address
First Line	:	2199 S UNIV BLVD
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80210-4711
Country	:	US
Telephone Number	:	321-332-2972
Fax Number	:

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

Provider Enumeration Date	:	02/07/2023
Last Update Date	:	02/07/2023

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