MEDICARE: CHARITY TYREE HALE 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	0126000723	VA

General Provider Information

NPI Number	:	1730501149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARITY TYREE HALE ATC

Provider Business Mailing Address
First Line	:	340 E WALNUT ST
Second Line	:
City	:	COVINGTON
State	:	VA
Zip	:	24426-1860
Country	:	US
Telephone Number	:	540-965-1400
Fax Number	:	540-965-1404

Provider Business Practice Location Address
First Line	:	606 S LEXINGTON AVE
Second Line	:
City	:	COVINGTON
State	:	VA
Zip	:	24426-1900
Country	:	US
Telephone Number	:	540-965-1410
Fax Number	:	540-965-5870

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

Provider Enumeration Date	:	01/21/2014
Last Update Date	:	01/21/2014

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