MEDICARE: MISS STACEY BAYNHAM ATC SCAT

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	282	SC

General Provider Information

NPI Number	:	1740686716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS STACEY BAYNHAM ATC SCAT

Provider Business Mailing Address
First Line	:	111 SPILLWAY BLVD
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29072-3418
Country	:	US
Telephone Number	:	843-446-1954
Fax Number	:

Provider Business Practice Location Address
First Line	:	320 CORLEY MILL RD
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29072-8403
Country	:	US
Telephone Number	:	803-821-0848
Fax Number	:

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

Provider Enumeration Date	:	11/18/2014
Last Update Date	:	11/18/2014

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