Healthcare Provider Details

I. General information

NPI: 1861483661
Provider Name (Legal Business Name): NATIONAL ATHLETIC HEALTH CARE ALLIANCE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 MOREHOUSE RD
EASTON CT
06612-1638
US

IV. Provider business mailing address

3955 W RAVENGUARD RD
PAULDEN AZ
86334-4312
US

V. Phone/Fax

Practice location:
  • Phone: 928-636-9053
  • Fax:
Mailing address:
  • Phone: 928-636-9053
  • Fax: 928-636-2270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number1729
License Number StateCT

VIII. Authorized Official

Name: MS. CYNTHIA VENTRICELLI
Title or Position: ADMINISTRATOR
Credential:
Phone: 928-636-9053