Healthcare Provider Details

I. General information

NPI: 1861676140
Provider Name (Legal Business Name): MARY AGNES KARLO ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2007
Last Update Date: 12/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 CEDAR AVE
RUMSON NJ
07760-1710
US

IV. Provider business mailing address

21 CEDAR AVE
RUMSON NJ
07760-1710
US

V. Phone/Fax

Practice location:
  • Phone: 908-309-1984
  • Fax:
Mailing address:
  • Phone: 908-309-1984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberMT 00261
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: