Healthcare Provider Details

I. General information

NPI: 1144639931
Provider Name (Legal Business Name): JUSTIN WIERENGA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 MICHIGAN AVE NE
WASHINGTON DC
20064-0001
US

IV. Provider business mailing address

243 14TH ST NE APARTMENT 2
WASHINGTON DC
20002-6413
US

V. Phone/Fax

Practice location:
  • Phone: 202-319-6049
  • Fax: 202-319-4752
Mailing address:
  • Phone: 616-706-1465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: