Healthcare Provider Details

I. General information

NPI: 1407883440
Provider Name (Legal Business Name): DENNIS JOHN PETRUCCI A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 02/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4760 ORTEN ST
SAN DIEGO CA
92110-1321
US

IV. Provider business mailing address

4760 ORTEN ST
SAN DIEGO CA
92110-1321
US

V. Phone/Fax

Practice location:
  • Phone: 858-775-7680
  • Fax:
Mailing address:
  • Phone: 858-775-7680
  • Fax:

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: