MEDICARE: MARISA MALEIKE 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	1595	TN

General Provider Information

NPI Number	:	1437590171
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISA MALEIKE ATC, LAT

Provider Business Mailing Address
First Line	:	650 DECKER DR
Second Line	:
City	:	MIAMISBURG
State	:	OH
Zip	:	45342-3949
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1551 LAKE LOUDON BLVD
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37916-4009
Country	:	US
Telephone Number	:	865-974-1231
Fax Number	:

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

Provider Enumeration Date	:	07/10/2013
Last Update Date	:	07/10/2013

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