Healthcare Provider Details

I. General information

NPI: 1689959975
Provider Name (Legal Business Name): MICHELE M DEMARTINO ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2011
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 MILLBURN AVE SUITE 102
MILLBURN NJ
07041-1738
US

IV. Provider business mailing address

235 MILLBURN AVE SUITE 102
MILLBURN NJ
07041-1738
US

V. Phone/Fax

Practice location:
  • Phone: 973-258-1177
  • Fax: 973-258-8181
Mailing address:
  • Phone: 973-258-1177
  • Fax: 973-258-8181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: