Healthcare Provider Details

I. General information

NPI: 1538856414
Provider Name (Legal Business Name): JUSTIN F VELASCO LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2023
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 E MORRIS AVE APT 2
LINDEN NJ
07036-3277
US

IV. Provider business mailing address

22 E MORRIS AVE APT 2
LINDEN NJ
07036-3277
US

V. Phone/Fax

Practice location:
  • Phone: 201-705-7774
  • Fax:
Mailing address:
  • Phone: 201-705-7774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00332000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: