MEDICARE: MR. BRIAN KEITH PICKERING 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	1624	MN

General Provider Information

NPI Number	:	1821194697
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN KEITH PICKERING ATC

Provider Business Mailing Address
First Line	:	2511 18TH ST S
Second Line	:
City	:	MOORHEAD
State	:	MN
Zip	:	56560-4810
Country	:	US
Telephone Number	:	218-770-4900
Fax Number	:

Provider Business Practice Location Address
First Line	:	615 S MILL ST
Second Line	:
City	:	FERGUS FALLS
State	:	MN
Zip	:	56537-2756
Country	:	US
Telephone Number	:	218-739-6889
Fax Number	:	218-739-5501

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

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	04/30/2015

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