Healthcare Provider Details

I. General information

NPI: 1649387267
Provider Name (Legal Business Name): BILL VELASCO ATHLETIC TRAINER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27643 REDWOOD WAY
CASTAIC CA
91384-4120
US

IV. Provider business mailing address

27643 REDWOOD WAY
CASTAIC CA
91384-4120
US

V. Phone/Fax

Practice location:
  • Phone: 310-233-4116
  • Fax: 310-233-4654
Mailing address:
  • Phone: 310-233-4116
  • Fax: 310-233-4654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: