MEDICARE: DOMINIQUE M STARR 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	003999	OH

General Provider Information

NPI Number	:	1801280656
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE M STARR ATC

Provider Business Mailing Address
First Line	:	1923 MALCOM DR
Second Line	:
City	:	KETTERING
State	:	OH
Zip	:	45420-3625
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1923 MALCOM DR
Second Line	:
City	:	KETTERING
State	:	OH
Zip	:	45420-3625
Country	:	US
Telephone Number	:	440-864-9449
Fax Number	:

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

Provider Enumeration Date	:	03/18/2015
Last Update Date	:	03/18/2015

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