Healthcare Provider Details

I. General information

NPI: 1417467648
Provider Name (Legal Business Name): JASMINE ALYSE ANGUIANO ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 10/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 CENTRAL AVE
OXNARD CA
93036-1045
US

IV. Provider business mailing address

2201 LAVANDA DR
OXNARD CA
93036-2509
US

V. Phone/Fax

Practice location:
  • Phone: 805-278-5500
  • Fax:
Mailing address:
  • Phone: 805-889-2028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000022826
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: