Healthcare Provider Details

I. General information

NPI: 1073641841
Provider Name (Legal Business Name): MICHAEL JOSEPH FLYNN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 WEYMOUTH RD
ENFIELD CT
06082
US

IV. Provider business mailing address

51 INDIAN RUN
ENFIELD CT
06082-4633
US

V. Phone/Fax

Practice location:
  • Phone: 860-763-7625
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number000177
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: