Healthcare Provider Details

I. General information

NPI: 1003520644
Provider Name (Legal Business Name): NADIA VISCO LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 LAUREL AVE
WELLESLEY MA
02481-7523
US

IV. Provider business mailing address

176 OAKLEIGH RD
NEWTON MA
02458-2224
US

V. Phone/Fax

Practice location:
  • Phone: 781-237-5585
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3735
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: