MEDICARE: MRS. STACEY JENSEN RITTER ATC

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

General Provider Information

NPI Number	:	1609803642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACEY JENSEN RITTER ATC

Provider Business Mailing Address
First Line	:	50 MALIBU CT
Second Line	:
City	:	GROVER BEACH
State	:	CA
Zip	:	93433-2821
Country	:	US
Telephone Number	:	805-788-0805
Fax Number	:	805-788-0845

Provider Business Practice Location Address
First Line	:	805 AEROVISTA PL
Second Line	:	STE 201
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-7919
Country	:	US
Telephone Number	:	805-788-0805
Fax Number	:	805-788-0845

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

Provider Enumeration Date	:	06/26/2006
Last Update Date	:	07/08/2007

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