Healthcare Provider Details

I. General information

NPI: 1174568943
Provider Name (Legal Business Name): AMANDA RUTH RICE A.T.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 1/2 GOLDENROD AVE
CORONA DEL MAR CA
92625-2145
US

IV. Provider business mailing address

612 1/2 GOLDENROD AVE
CORONA DEL MAR CA
92625-2145
US

V. Phone/Fax

Practice location:
  • Phone: 714-745-2927
  • Fax:
Mailing address:
  • Phone: 714-745-2927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: