Healthcare Provider Details

I. General information

NPI: 1114392925
Provider Name (Legal Business Name): JOSEPH BALTAZAR MURILLO LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2015
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 SW 18TH TER APT 1607
FORT LAUDERDALE FL
33315-2249
US

IV. Provider business mailing address

2550 SW 18TH TER APT 1607
FORT LAUDERDALE FL
33315-2249
US

V. Phone/Fax

Practice location:
  • Phone: 954-646-3243
  • Fax:
Mailing address:
  • Phone: 954-646-3243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL 1493
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: