MEDICARE: HAILEY ELIZABETH ROCKWOOD MS, ATC/L

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	10878993-4810	UT

General Provider Information

NPI Number	:	1710467485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HAILEY ELIZABETH ROCKWOOD MS, ATC/L

Provider Business Mailing Address
First Line	:	5690 KINGSFORD AVE
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-6309
Country	:	US
Telephone Number	:	435-714-0607
Fax Number	:

Provider Business Practice Location Address
First Line	:	1840 S 1300 E
Second Line	:	PAYNE GYMNASIUM RM 105
City	:	SALT LAKE
State	:	UT
Zip	:	84105
Country	:	US
Telephone Number	:	435-714-0607
Fax Number	:

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

Provider Enumeration Date	:	08/21/2018
Last Update Date	:	08/21/2018

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