MEDICARE: MR. MACKENZIE LUKE MCDONALD ATC, CSCS

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	AT.0001008	CO

General Provider Information

NPI Number	:	1598870602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MACKENZIE LUKE MCDONALD ATC, CSCS

Provider Business Mailing Address
First Line	:	1114 CYPRESS DR
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-4116
Country	:	US
Telephone Number	:	970-213-6029
Fax Number	:

Provider Business Practice Location Address
First Line	:	COLORADO STATE UNIVERSITY DEPT 0120
Second Line	:	MOBY 141
City	:	FORT COLLINS
State	:	CO
Zip	:	80523-0001
Country	:	US
Telephone Number	:	970-491-6756
Fax Number	:

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

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	07/06/2016

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