MEDICARE: BRANDI RAE SPENCER A.T.C.

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

General Provider Information

NPI Number	:	1851435796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDI RAE SPENCER A.T.C.

Provider Business Mailing Address
First Line	:	1503 DUTCH HOLLOW RD
Second Line	:
City	:	DUNBAR
State	:	WV
Zip	:	25064-1200
Country	:	US
Telephone Number	:	304-388-4900
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 TRACY WAY
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25311-1258
Country	:	US
Telephone Number	:	304-388-4900
Fax Number	:	304-388-4910

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

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	07/08/2007

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