MEDICARE: MR. JAMIE LEE BUTIKOFER 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	AT000323	GA

General Provider Information

NPI Number	:	1750468567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMIE LEE BUTIKOFER ATC

Provider Business Mailing Address
First Line	:	PO BOX 743
Second Line	:
City	:	DEMOREST
State	:	GA
Zip	:	30535
Country	:	US
Telephone Number	:	706-778-7161
Fax Number	:	706-776-3020

Provider Business Practice Location Address
First Line	:	171 RAIDER CIR
Second Line	:
City	:	MOUNT AIRY
State	:	GA
Zip	:	30563-3065
Country	:	US
Telephone Number	:	706-778-7161
Fax Number	:	706-776-3020

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/08/2007

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