MEDICARE: MR. TERENCE MCGRATH AGGELER JR. ATC, LPTA

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

General Provider Information

NPI Number	:	1902894132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TERENCE MCGRATH AGGELER JR. ATC, LPTA

Provider Business Mailing Address
First Line	:	575 RIVERGATE
Second Line	:	SUITE 208
City	:	DURANGO
State	:	CO
Zip	:	81301-7487
Country	:	US
Telephone Number	:	970-382-8776
Fax Number	:	970-382-9746

Provider Business Practice Location Address
First Line	:	575 RIVERGATE
Second Line	:	SUITE 208
City	:	DURANGO
State	:	CO
Zip	:	81301-7487
Country	:	US
Telephone Number	:	970-382-8776
Fax Number	:	970-382-9746

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

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	08/07/2007

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