MEDICARE: CAMERON STREET LAT, 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	1951	AL

General Provider Information

NPI Number	:	1871062174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMERON STREET LAT, ATC

Provider Business Mailing Address
First Line	:	4308 RICHARDSON DR NW
Second Line	:
City	:	HUNTSVILLE
State	:	AL
Zip	:	35816-3528
Country	:	US
Telephone Number	:	307-763-1886
Fax Number	:

Provider Business Practice Location Address
First Line	:	4308 RICHARDSON DR NW
Second Line	:
City	:	HUNTSVILLE
State	:	AL
Zip	:	35816-3528
Country	:	US
Telephone Number	:	307-763-1886
Fax Number	:

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

Provider Enumeration Date	:	11/15/2018
Last Update Date	:	11/15/2018

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Directions to “ CAMERON STREET LAT, ATC” Practice Location

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