MEDICARE: EMERALD DAMGE 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	AT.0001688	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NA	OTHER		NA

General Provider Information

NPI Number	:	1881108637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMERALD DAMGE ATC

Provider Business Mailing Address
First Line	:	2542 ORCHARD PL
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-3117
Country	:	US
Telephone Number	:	970-227-7487
Fax Number	:

Provider Business Practice Location Address
First Line	:	2542 ORCHARD PL
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80521-3117
Country	:	US
Telephone Number	:	970-227-7487
Fax Number	:

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

Provider Enumeration Date	:	11/30/2017
Last Update Date	:	11/30/2017

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