MEDICARE: LARAMIE ANN GLOVER

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	ATR-LAT-LIC-2926	MT
2	2255A2300X	Athletic Trainer	14063560-4810	UT
3	2255A2300X	Athletic Trainer

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2000055578	OTHER		NATA BOC

General Provider Information

NPI Number	:	1790569325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARAMIE ANN GLOVER

Provider Business Mailing Address
First Line	:	1025 COUNTY ROAD 388
Second Line	:
City	:	FALLS CITY
State	:	TX
Zip	:	78113-3048
Country	:	US
Telephone Number	:	830-391-2702
Fax Number	:

Provider Business Practice Location Address
First Line	:	1025 COUNTY ROAD 388
Second Line	:
City	:	FALLS CITY
State	:	TX
Zip	:	78113-3048
Country	:	US
Telephone Number	:	830-391-2702
Fax Number	:

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

Provider Enumeration Date	:	08/23/2023
Last Update Date	:	07/11/2024

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Directions to “ LARAMIE ANN GLOVER ” Practice Location

Language	Start Address	Practice Location

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