MEDICARE: KEN STATZ

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	:	1508399643
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEN STATZ

Provider Business Mailing Address
First Line	:	215 N LOOP 1604 E APT 4306
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78232-1280
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	215 N LOOP 1604 E APT 4306
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78232-1280
Country	:	US
Telephone Number	:	210-717-6910
Fax Number	:

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

Provider Enumeration Date	:	04/05/2017
Last Update Date	:	04/05/2017

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Directions to “ KEN STATZ ” Practice Location

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