Healthcare Provider Details

I. General information

NPI: 1821554635
Provider Name (Legal Business Name): JOLIE TANG ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SWAN ST
BATON ROUGE LA
70813-2260
US

IV. Provider business mailing address

116 ELIZABETH AVE
ISELIN NJ
08830-2260
US

V. Phone/Fax

Practice location:
  • Phone: 225-771-2712
  • Fax:
Mailing address:
  • Phone: 732-598-0598
  • 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: