Healthcare Provider Details

I. General information

NPI: 1871959403
Provider Name (Legal Business Name): LAUREN DYKEMA ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2016
Last Update Date: 02/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 M ST
MERCED CA
95348-2806
US

IV. Provider business mailing address

3600 M ST
MERCED CA
95348-2806
US

V. Phone/Fax

Practice location:
  • Phone: 209-384-6275
  • Fax:
Mailing address:
  • Phone: 209-384-6275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: