MEDICARE: CAROL ANN-RUDER GATES 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

General Provider Information

NPI Number	:	1497898787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROL ANN-RUDER GATES A.T.C

Provider Business Mailing Address
First Line	:	514 PARK RD
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49203-4526
Country	:	US
Telephone Number	:	517-796-0748
Fax Number	:

Provider Business Practice Location Address
First Line	:	106 E MAIN ST
Second Line	:
City	:	SPRING ARBOR
State	:	MI
Zip	:	49283-9701
Country	:	US
Telephone Number	:	517-750-6506
Fax Number	:	517-750-2745

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

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	07/08/2007

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