MEDICARE: STEFAN ALVIDREZ 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		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2000037733	OTHER		BOARD OF CERTIFICATION OF ATHLETIC TRAINERS

General Provider Information

NPI Number	:	1962939843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEFAN ALVIDREZ MS, ATC

Provider Business Mailing Address
First Line	:	7313 N DE WOLF AVE.
Second Line	:
City	:	CLOVIS
State	:	CA
Zip	:	93619
Country	:	US
Telephone Number	:	253-736-4391
Fax Number	:

Provider Business Practice Location Address
First Line	:	7313 N DE WOLF AVE
Second Line	:
City	:	CLOVIS
State	:	CA
Zip	:	93619-9239
Country	:	US
Telephone Number	:	253-736-4391
Fax Number	:

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

Provider Enumeration Date	:	05/22/2017
Last Update Date	:	02/24/2023

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