MEDICARE: MR. JASON TREVOR ROBERTS ATC, CSCS

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	AL 1543	FL

General Provider Information

NPI Number	:	1487630034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JASON TREVOR ROBERTS ATC, CSCS

Provider Business Mailing Address
First Line	:	509 STATE ST
Second Line	:
City	:	SCRANTON
State	:	IA
Zip	:	51462-8418
Country	:	US
Telephone Number	:	772-559-5703
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 ELYSIAN PARK AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90012-1112
Country	:	US
Telephone Number	:	323-224-1500
Fax Number	:

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

Provider Enumeration Date	:	12/15/2005
Last Update Date	:	07/08/2007

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