Healthcare Provider Details

I. General information

NPI: 1780120550
Provider Name (Legal Business Name): KYRA BUSQUE LAT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 COLLEGE ST KENDALL DANCE AND SPORTS COMPLEX ROOM 126A
SOUTH HADLEY MA
01075-1423
US

IV. Provider business mailing address

4 DOBSON RD
VERNON CT
06066-5430
US

V. Phone/Fax

Practice location:
  • Phone: 413-538-3316
  • Fax:
Mailing address:
  • Phone: 860-888-2789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2934
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: