MEDICARE: MR. GREGORY GEORGE BOZEKA 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	002630	OH

General Provider Information

NPI Number	:	1508838046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREGORY GEORGE BOZEKA LAT

Provider Business Mailing Address
First Line	:	217 CORDELIA ST SW
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-3503
Country	:	US
Telephone Number	:	330-497-7295
Fax Number	:

Provider Business Practice Location Address
First Line	:	OHIO UNIVERSITY
Second Line	:	GROVER E207
City	:	ATHENS
State	:	OH
Zip	:	45701-2979
Country	:	US
Telephone Number	:	740-593-9497
Fax Number	:

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

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

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