Healthcare Provider Details

I. General information

NPI: 1881765261
Provider Name (Legal Business Name): TONY CHRISTOPHER HANECA MED, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 15TH AVE S
FARGO ND
58103-3824
US

IV. Provider business mailing address

3022 34TH ST S
MOORHEAD MN
56560-6937
US

V. Phone/Fax

Practice location:
  • Phone: 701-446-2049
  • Fax:
Mailing address:
  • Phone: 218-359-0723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number295-04
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: