Healthcare Provider Details

I. General information

NPI: 1710411236
Provider Name (Legal Business Name): JOHN JUNIET A.T.C., L.A.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2017
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 ELM ST
MERIDEN CT
06450-5808
US

IV. Provider business mailing address

228 ELM STREET
MERIDEN CT
06450
US

V. Phone/Fax

Practice location:
  • Phone: 203-499-8301
  • Fax:
Mailing address:
  • Phone: 203-499-8301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1215
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number1215
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: