Healthcare Provider Details

I. General information

NPI: 1225539950
Provider Name (Legal Business Name): JESSE TOTORO MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 PENNINGTON RD
EWING NJ
08618-1301
US

IV. Provider business mailing address

1102 STURWOOD WAY
LAWRENCEVILLE NJ
08648-1521
US

V. Phone/Fax

Practice location:
  • Phone: 609-619-2000
  • Fax:
Mailing address:
  • Phone: 609-221-5486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00186100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: