MEDICARE: SAMANTHA LUCILLE RADEL ATC, 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	000641	IA

General Provider Information

NPI Number	:	1710125455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA LUCILLE RADEL ATC, LAT

Provider Business Mailing Address
First Line	:	100 WARTBURG BLVD
Second Line	:	DEPARTMENT OF ATHLETICS-WARTBURG COLLEGE
City	:	WAVERLY
State	:	IA
Zip	:	50677-2215
Country	:	US
Telephone Number	:	319-352-8725
Fax Number	:	319-352-8528

Provider Business Practice Location Address
First Line	:	100 WARTBURG BLVD
Second Line	:	DEPARTMENT OF ATHLETICS-WARTBURG COLLEGE
City	:	WAVERLY
State	:	IA
Zip	:	50677-2215
Country	:	US
Telephone Number	:	319-352-8725
Fax Number	:	319-352-8528

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

Provider Enumeration Date	:	02/03/2009
Last Update Date	:	02/03/2009

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