Healthcare Provider Details

I. General information

NPI: 1780906636
Provider Name (Legal Business Name): BRIAN THOMAS LATINO ATC, PES, CES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2010
Last Update Date: 02/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 BRADFORD WAY
MILL VALLEY CA
94941
US

IV. Provider business mailing address

10 BRADFORD WAY
MILL VALLEY CA
94941
US

V. Phone/Fax

Practice location:
  • Phone: 415-388-8436
  • Fax:
Mailing address:
  • Phone: 415-388-8436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number020602046
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: