Healthcare Provider Details

I. General information

NPI: 1548037187
Provider Name (Legal Business Name): ALEX FERNANDO ALVAREZ ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2023
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2095 HILLSIDE RD UNIT 1110
STORRS CT
06269-1110
US

IV. Provider business mailing address

1 ROYCE CIR STE 104
STORRS CT
06268-2270
US

V. Phone/Fax

Practice location:
  • Phone: 860-486-1121
  • Fax:
Mailing address:
  • Phone: 860-487-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1522
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: