MEDICARE: KRYSTINA AGUILERA MS, 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	:	1568969277
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTINA AGUILERA MS, ATC

Provider Business Mailing Address
First Line	:	2594 N FITZSIMMONS AVE
Second Line	:
City	:	RIALTO
State	:	CA
Zip	:	92377-4170
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9635 GREENLEAF AVE
Second Line	:
City	:	SANTA FE SPRINGS
State	:	CA
Zip	:	90670-3001
Country	:	US
Telephone Number	:	909-900-5195
Fax Number	:

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

Provider Enumeration Date	:	04/09/2018
Last Update Date	:	04/09/2018

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