MEDICARE: MR. STEPHEN LUBBEHUSEN ATC,LAT

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	36000286A	IN

General Provider Information

NPI Number	:	1942639406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STEPHEN LUBBEHUSEN ATC,LAT

Provider Business Mailing Address
First Line	:	10807 SMOKEY RIDGE PL
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-8876
Country	:	US
Telephone Number	:	260-490-9957
Fax Number	:

Provider Business Practice Location Address
First Line	:	10807 SMOKEY RIDGE PL
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-8876
Country	:	US
Telephone Number	:	260-490-9957
Fax Number	:

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

Provider Enumeration Date	:	11/05/2013
Last Update Date	:	11/05/2013

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