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NPI Code Detail

MEDICARE: MR. TIMOTHY JOHN DESMARTEAU ATC/L

MEDICARE: MR. TIMOTHY JOHN DESMARTEAU ATC/L
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
12255A2300XAthletic TrainerAL 285FL

General Provider Information

NPI Number : 1558324244
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. TIMOTHY JOHN DESMARTEAU ATC/L
Provider Business Mailing Address
First Line : 1435 AVENUE H NE
Second Line :
City : WINTER HAVEN
State : FL
Zip : 33881-4353
Country : US
Telephone Number : 352-267-7619
Fax Number : 863-638-2915
Provider Business Practice Location Address
First Line : 1201 N SCENIC HWY
Second Line :
City : BABSON PARK
State : FL
Zip : 33827-9751
Country : US
Telephone Number : 863-638-2949
Fax Number : 863-638-2915
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/11/2006
Last Update Date : 07/08/2007

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