Healthcare Provider Details

I. General information

NPI: 1750755260
Provider Name (Legal Business Name): CORA CELIA CORDOVA ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2015
Last Update Date: 11/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 ONTARIO CT
EL CAJON CA
92019-4231
US

IV. Provider business mailing address

2011 ONTARIO CT
EL CAJON CA
92019-4231
US

V. Phone/Fax

Practice location:
  • Phone: 619-997-2649
  • Fax:
Mailing address:
  • Phone: 619-997-2649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000022813
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: