Healthcare Provider Details

I. General information

NPI: 1497523872
Provider Name (Legal Business Name): BREANNA NICOLE LEWENTHAL ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2023
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 JACARANDA DR
EL CENTRO CA
92243-6159
US

IV. Provider business mailing address

951 JACARANDA DR
EL CENTRO CA
92243-6159
US

V. Phone/Fax

Practice location:
  • Phone: 310-321-8567
  • Fax:
Mailing address:
  • Phone: 310-321-8567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000031933
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: