Healthcare Provider Details

I. General information

NPI: 1588790513
Provider Name (Legal Business Name): WILLIAM MARK COFFEY LAT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 CENTER ROAD
DUDLEY MA
01571
US

IV. Provider business mailing address

79 KOSMAS ST
MARLBOROUGH MA
01752-2535
US

V. Phone/Fax

Practice location:
  • Phone: 508-213-2261
  • Fax: 508-213-2446
Mailing address:
  • Phone: 508-460-0342
  • Fax: 508-213-2446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1426-AT
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: