Healthcare Provider Details

I. General information

NPI: 1801332275
Provider Name (Legal Business Name): JOEL MASSOBRIO AT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2017
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 PAGE AVE
JACKSON MI
49201-2418
US

IV. Provider business mailing address

2600 E ALPINE LAKE DR APT D
JACKSON MI
49203-6339
US

V. Phone/Fax

Practice location:
  • Phone: 877-202-2175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001523
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: