MEDICARE: JOHN CLIFTON CHULADA 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	00110	NH

General Provider Information

NPI Number	:	1639106271
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN CLIFTON CHULADA ATC

Provider Business Mailing Address
First Line	:	20 JONATHAN LN
Second Line	:
City	:	BOW
State	:	NH
Zip	:	03304-3713
Country	:	US
Telephone Number	:	603-228-2210
Fax Number	:	603-228-2212

Provider Business Practice Location Address
First Line	:	ASSOCIATED GROCERS OF NEW ENGLAND
Second Line	:	11 COOPERATIVE WAY
City	:	PEMBROKE
State	:	NH
Zip	:	03275
Country	:	US
Telephone Number	:	603-223-5699
Fax Number	:

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

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	11/22/2024

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