MEDICARE: MRS. HEIDI JOANNE DALLE AVE THOMPSON A.T.C.

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	36000412A	IN

General Provider Information

NPI Number	:	1447224753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HEIDI JOANNE DALLE AVE THOMPSON A.T.C.

Provider Business Mailing Address
First Line	:	6702 FAIRWOOD DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46256-3220
Country	:	US
Telephone Number	:	317-577-8471
Fax Number	:	317-884-5365

Provider Business Practice Location Address
First Line	:	5255 E STOP 11 RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46237-6341
Country	:	US
Telephone Number	:	317-884-5265
Fax Number	:	317-884-5365

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

Provider Enumeration Date	:	02/14/2006
Last Update Date	:	07/08/2007

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