MEDICARE: NATALIA SUMODJO M.S., LAT, ATC, CES

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	306799	LA

General Provider Information

NPI Number	:	1851886725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATALIA SUMODJO M.S., LAT, ATC, CES

Provider Business Mailing Address
First Line	:	5200 NELSON RD APT 516
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-0810
Country	:	US
Telephone Number	:	415-259-1403
Fax Number	:

Provider Business Practice Location Address
First Line	:	5200 NELSON RD APT 516
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-0810
Country	:	US
Telephone Number	:	415-259-1403
Fax Number	:

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

Provider Enumeration Date	:	06/24/2018
Last Update Date	:	06/24/2018

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