MEDICARE: VICTORIA A KEAN 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	AL 1944	FL

General Provider Information

NPI Number	:	1871791459
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTORIA A KEAN ATC

Provider Business Mailing Address
First Line	:	29300 BIRDS EYE DR
Second Line	:
City	:	WESLEY CHAPEL
State	:	FL
Zip	:	33543-6571
Country	:	US
Telephone Number	:	813-477-8215
Fax Number	:

Provider Business Practice Location Address
First Line	:	12901 BRUCE B DOWNS BLVD
Second Line	:	STE 4161, MDC 36
City	:	TAMPA
State	:	FL
Zip	:	33612-4742
Country	:	US
Telephone Number	:	813-396-9625
Fax Number	:

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

Provider Enumeration Date	:	07/05/2007
Last Update Date	:	07/08/2007

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