Healthcare Provider Details

I. General information

NPI: 1669701264
Provider Name (Legal Business Name): BRIAN D FANNING JR. MS, ACI, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2009
Last Update Date: 12/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 WOOD DUCK CT
HACKETTSTOWN NJ
07840-3312
US

IV. Provider business mailing address

22 WOOD DUCK CT
HACKETTSTOWN NJ
07840-3312
US

V. Phone/Fax

Practice location:
  • Phone: 973-229-6280
  • Fax: 973-353-1431
Mailing address:
  • Phone: 973-229-6280
  • Fax: 973-353-1431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00122800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: