Healthcare Provider Details

I. General information

NPI: 1487007209
Provider Name (Legal Business Name): ALLAN BEWERSDORF JR. LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2016
Last Update Date: 07/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 16TH ST
VERO BEACH FL
32960-3626
US

IV. Provider business mailing address

1707 16TH ST
VERO BEACH FL
32960-3626
US

V. Phone/Fax

Practice location:
  • Phone: 772-564-5494
  • Fax:
Mailing address:
  • Phone: 772-564-5494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL1525
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: