MEDICARE: DUSTY JOE SMITH 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		CA

General Provider Information

NPI Number	:	1851517411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUSTY JOE SMITH A.T.C.

Provider Business Mailing Address
First Line	:	1328 19TH ST APT A
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90404-1926
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 S BARRINGTON PL
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-3306
Country	:	US
Telephone Number	:	310-889-2794
Fax Number	:

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

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	07/08/2007

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