MEDICARE: MR. ANDRE DANIEL ATC, CSCS, NASM-PES

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		WI

General Provider Information

NPI Number	:	1790758951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANDRE DANIEL ATC, CSCS, NASM-PES

Provider Business Mailing Address
First Line	:	8961 S CHICAGO RD
Second Line	:
City	:	OAK CREEK
State	:	WI
Zip	:	53154-4249
Country	:	US
Telephone Number	:	414-559-6680
Fax Number	:

Provider Business Practice Location Address
First Line	:	3501 S LAKE DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53235-0900
Country	:	US
Telephone Number	:	414-294-4900
Fax Number	:

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

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	07/08/2007

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