Healthcare Provider Details

I. General information

NPI: 1316721855
Provider Name (Legal Business Name): MIXED ATHLETIC PERFORMANCE TRAINING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8665 AUBURN FOLSOM RD
GRANITE BAY CA
95746-8510
US

IV. Provider business mailing address

8665 AUBURN FOLSOM RD
GRANITE BAY CA
95746-8510
US

V. Phone/Fax

Practice location:
  • Phone: 916-642-9942
  • Fax:
Mailing address:
  • Phone: 916-642-9942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GREG SIEWERS
Title or Position: CEO
Credential: CPT
Phone: 916-642-9942