MEDICARE: JIANNA MICHELLE AGUILAR 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

General Provider Information

NPI Number	:	1033731005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIANNA MICHELLE AGUILAR ATC

Provider Business Mailing Address
First Line	:	4141 COLUMBIA AVE
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92501-1553
Country	:	US
Telephone Number	:	951-533-2358
Fax Number	:

Provider Business Practice Location Address
First Line	:	16150 POMONA RINCON RD
Second Line	:
City	:	CHINO HILLS
State	:	CA
Zip	:	91709-3101
Country	:	US
Telephone Number	:	909-606-7540
Fax Number	:

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

Provider Enumeration Date	:	05/13/2020
Last Update Date	:	05/13/2020

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