Healthcare Provider Details

I. General information

NPI: 1306874300
Provider Name (Legal Business Name): KRISTIN J. LAGE M.S., ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UCLA INTERCOLLEGIATE ATHLETICS 175 MORGAN CENTER; BOX 951639
LOS ANGELES CA
90095-1639
US

IV. Provider business mailing address

302 S. VINE ST. P.O. BOX 254
ROLAND IA
50236-0254
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-6107
  • Fax:
Mailing address:
  • Phone: 515-388-4681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-1081
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: