MEDICARE: RACHELLE BLINOFF-MUDD 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	:	1558732313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RACHELLE BLINOFF-MUDD ATC

Provider Business Mailing Address
First Line	:	5125 BRIGGS AVE
Second Line	:
City	:	LA CRESCENTA
State	:	CA
Zip	:	91214-3002
Country	:	US
Telephone Number	:	657-217-0580
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 OTTERBEIN AVE
Second Line	:
City	:	ROWLAND HEIGHTS
State	:	CA
Zip	:	91748-3949
Country	:	US
Telephone Number	:	657-217-0580
Fax Number	:

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

Provider Enumeration Date	:	10/19/2015
Last Update Date	:	10/19/2015

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