Healthcare Provider Details

I. General information

NPI: 1528096393
Provider Name (Legal Business Name): MARC FABIAN NORCROSS MA, ATC
Entity Type: Individual
Gender: Male
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 ATHLETIC DEPARTMENT 325 WESTWOOD PLAZA
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

1703 1/2 MANHATTAN AVE
HERMOSA BEACH CA
90254-3456
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-3335
  • Fax: 310-206-6107
Mailing address:
  • Phone: 310-372-7387
  • Fax: 310-206-1985

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: