MEDICARE: MR. H. KEITH OWSLEY 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		WI

General Provider Information

NPI Number	:	1598785768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. H. KEITH OWSLEY LAT

Provider Business Mailing Address
First Line	:	5915 SANDVIEW LN
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53406-1173
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4050 LIGHTHOUSE DR
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53402-3114
Country	:	US
Telephone Number	:	262-260-7857
Fax Number	:

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

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/08/2007

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