MEDICARE: MISS CRYSTAL V SMALL 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	AT001359	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2255A2300X	OTHER	GA	ATHLETIC TRAINER

General Provider Information

NPI Number	:	1871618231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CRYSTAL V SMALL ATC

Provider Business Mailing Address
First Line	:	111 POND DR
Second Line	:
City	:	KATHLEEN
State	:	GA
Zip	:	31047-3202
Country	:	US
Telephone Number	:	478-987-2754
Fax Number	:	478-987-2749

Provider Business Practice Location Address
First Line	:	1005 STATE UNIVERSITY DR
Second Line	:	DEPARTMENT OF ATHLETICS
City	:	FORT VALLEY
State	:	GA
Zip	:	31030-4313
Country	:	US
Telephone Number	:	478-825-6195
Fax Number	:	478-825-6886

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

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	02/21/2008

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