Healthcare Provider Details

I. General information

NPI: 1932672425
Provider Name (Legal Business Name): KATIE LYN OSTROVECKY MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2019
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 MAIN ST
EL SEGUNDO CA
90245-3057
US

IV. Provider business mailing address

223 SHELDON ST
EL SEGUNDO CA
90245-3918
US

V. Phone/Fax

Practice location:
  • Phone: 703-489-2633
  • Fax:
Mailing address:
  • Phone: 703-489-2633
  • 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: