MEDICARE: KRISTA DAVIS WHITE 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	ATH.J00364	LA

General Provider Information

NPI Number	:	1760500219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTA DAVIS WHITE ATC, LAT

Provider Business Mailing Address
First Line	:	222 SAINT NICHOLAS ST
Second Line	:
City	:	LULING
State	:	LA
Zip	:	70070-5110
Country	:	US
Telephone Number	:	985-308-0263
Fax Number	:

Provider Business Practice Location Address
First Line	:	222 SAINT NICHOLAS ST
Second Line	:
City	:	LULING
State	:	LA
Zip	:	70070-5110
Country	:	US
Telephone Number	:	985-308-0263
Fax Number	:

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

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	07/08/2007

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