MEDICARE: BROOKE PETEFISH LAT, 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	0506409	NV

General Provider Information

NPI Number	:	1902359078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKE PETEFISH LAT, ATC

Provider Business Mailing Address
First Line	:	8065 CIMARRON MEADOWS WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-5054
Country	:	US
Telephone Number	:	623-229-2663
Fax Number	:

Provider Business Practice Location Address
First Line	:	8065 CIMARRON MEADOWS WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-5054
Country	:	US
Telephone Number	:	623-229-2663
Fax Number	:

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

Provider Enumeration Date	:	07/25/2016
Last Update Date	:	07/25/2016

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