MEDICARE: CASEY WIECK ATC, LMT

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	AT.003604	OH
2	225700000X	Massage Therapist	33.014715-T-Z	OH

General Provider Information

NPI Number	:	1770903288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASEY WIECK ATC, LMT

Provider Business Mailing Address
First Line	:	2368 EASTCLEFT DR
Second Line	:
City	:	UPPER ARLINGTON
State	:	OH
Zip	:	43221-1852
Country	:	US
Telephone Number	:	614-906-7766
Fax Number	:

Provider Business Practice Location Address
First Line	:	2368 EASTCLEFT DR
Second Line	:
City	:	UPPER ARLINGTON
State	:	OH
Zip	:	43221-1852
Country	:	US
Telephone Number	:	614-906-7766
Fax Number	:

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

Provider Enumeration Date	:	04/23/2014
Last Update Date	:	04/23/2014

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