Healthcare Provider Details

I. General information

NPI: 1487641031
Provider Name (Legal Business Name): LAWRENCE E VENIS ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 COMMONWEALTH AVE
BOSTON MA
02215-1394
US

IV. Provider business mailing address

370 OLD LANCASTER RD
SUDBURY MA
01776-2032
US

V. Phone/Fax

Practice location:
  • Phone: 617-353-7326
  • Fax: 617-358-7166
Mailing address:
  • Phone: 617-353-7326
  • Fax: 617-358-7166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number313
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: