Healthcare Provider Details

I. General information

NPI: 1013677251
Provider Name (Legal Business Name): DAYSJIA BLACK ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2021
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 1ST ST
HACKENSACK NJ
07601-2423
US

IV. Provider business mailing address

22 CRESCENT AVE
JERSEY CITY NJ
07304-2812
US

V. Phone/Fax

Practice location:
  • Phone: 201-646-7900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00250700
License Number StateNJ

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: