Healthcare Provider Details

I. General information

NPI: 1053528992
Provider Name (Legal Business Name): JILL MARIE AYRES MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

574 S SHASTA WAY
ORANGE CA
92869-5242
US

IV. Provider business mailing address

574 S SHASTA WAY
ORANGE CA
92869-5242
US

V. Phone/Fax

Practice location:
  • Phone: 714-633-7294
  • Fax: 714-633-8016
Mailing address:
  • Phone: 714-633-7294
  • Fax: 714-633-8016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number914010
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: