Healthcare Provider Details

I. General information

NPI: 1013462464
Provider Name (Legal Business Name): TRENT GRITZ ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 08/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 W COAL AVE
HOBBS NM
88240-1717
US

IV. Provider business mailing address

908 W COAL AVE
HOBBS NM
88240-1717
US

V. Phone/Fax

Practice location:
  • Phone: 405-609-4070
  • Fax:
Mailing address:
  • Phone: 405-609-4070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number432
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT4145
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: