MEDICARE: MRS. DAWN YORTON C-PED, 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	224L00000X	Pedorthist
2	2255A2300X	Athletic Trainer	3640200	MI

General Provider Information

NPI Number	:	1871987958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DAWN YORTON C-PED, ATC

Provider Business Mailing Address
First Line	:	10532 LITTLE FAWN CT
Second Line	:
City	:	LAKEVIEW
State	:	MI
Zip	:	48850-9326
Country	:	US
Telephone Number	:	616-498-2687
Fax Number	:

Provider Business Practice Location Address
First Line	:	5147 E PARIS AVE SE
Second Line	:	SUITE 21
City	:	KENTWOOD
State	:	MI
Zip	:	49512-5457
Country	:	US
Telephone Number	:	616-356-5030
Fax Number	:	616-656-5442

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

Provider Enumeration Date	:	03/26/2015
Last Update Date	:	03/26/2015

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