MEDICARE: MR. ZEVON M STUBBLEFIELD ATC, 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	AL 1729	FL

General Provider Information

NPI Number	:	1548284300
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ZEVON M STUBBLEFIELD ATC, LAT

Provider Business Mailing Address
First Line	:	4100 N 58TH AVE APT 102
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-1531
Country	:	US
Telephone Number	:	754-264-9154
Fax Number	:

Provider Business Practice Location Address
First Line	:	3301 COLLEGE AVE.
Second Line	:
City	:	FT. LAUDERDALE
State	:	FL
Zip	:	33314-7796
Country	:	US
Telephone Number	:	754-264-9154
Fax Number	:

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/08/2007

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