Healthcare Provider Details

I. General information

NPI: 1376308460
Provider Name (Legal Business Name): ALENA KOAY ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2024
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21615 BROOKSIDE CT
WALNUT CA
91789-1413
US

IV. Provider business mailing address

21615 BROOKSIDE CT
WALNUT CA
91789-1413
US

V. Phone/Fax

Practice location:
  • Phone: 909-569-5947
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberBOC366774
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: