MEDICARE: MR. KENNETH W LOCKER 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	AT0225	TX

General Provider Information

NPI Number	:	1871595280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH W LOCKER ATC

Provider Business Mailing Address
First Line	:	13519 LAMBERT LN
Second Line	:
City	:	ROANOKE
State	:	TX
Zip	:	76262-8099
Country	:	US
Telephone Number	:	214-354-1029
Fax Number	:

Provider Business Practice Location Address
First Line	:	13519 LAMBERT LN
Second Line	:
City	:	ROANOKE
State	:	TX
Zip	:	76262-8099
Country	:	US
Telephone Number	:	214-354-1029
Fax Number	:

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

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	07/08/2007

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