Healthcare Provider Details

I. General information

NPI: 1194842021
Provider Name (Legal Business Name): BENITO VELASQUEZ ATC LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2007
Last Update Date: 08/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 COLLEGE DR # 5142 UNIVERSITY OF SOUTHERN MISSISSIPPI
HATTIESBURG MS
39406-0001
US

IV. Provider business mailing address

3410 TAFT BLVD
WICHITA FALLS TX
76308-2099
US

V. Phone/Fax

Practice location:
  • Phone: 601-266-6058
  • Fax: 601-266-4445
Mailing address:
  • Phone: 940-397-4829
  • Fax: 940-397-4901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT 0113
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT4914
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: