Healthcare Provider Details

I. General information

NPI: 1962447623
Provider Name (Legal Business Name): MARNA MARIE YOUNGBERG ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8445 LAS VEGAS BLVD S #1150
LAS VEGAS NV
89123-1688
US

IV. Provider business mailing address

8445 LAS VEGAS BLVD S #1150
LAS VEGAS NV
89123-1688
US

V. Phone/Fax

Practice location:
  • Phone: 702-858-8737
  • Fax:
Mailing address:
  • Phone: 702-858-8737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: