Healthcare Provider Details

I. General information

NPI: 1578937686
Provider Name (Legal Business Name): TIMOTHY LUKE FENDER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2015
Last Update Date: 07/21/2022
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIRAHATA 64 MISAWA-KICHI BUILDING #656
MISAWA-SHI AOMORI-KEN
0330012
JP

IV. Provider business mailing address

PSC 76 BOX 2921
APO AP
96319-0030
US

V. Phone/Fax

Practice location:
  • Phone: 315-226-1051
  • Fax:
Mailing address:
  • Phone: 864-980-4005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2864
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: