Healthcare Provider Details

I. General information

NPI: 1710007174
Provider Name (Legal Business Name): GIUSEPPI BOMMARITO JR. I ATC, LAT, BS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 MEXICO RD SUITE 104
SAINT PETERS MO
63376-1666
US

IV. Provider business mailing address

612 LONGHORN DR
O FALLON MO
63368-6934
US

V. Phone/Fax

Practice location:
  • Phone: 636-939-9540
  • Fax:
Mailing address:
  • Phone: 636-939-9540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2004003803
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: