Healthcare Provider Details

I. General information

NPI: 1164467387
Provider Name (Legal Business Name): REBECCA DZIEKAN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 COLLEGE RD GENESEE COMMUNITY COLLEGE
BATAVIA NY
14020-9703
US

IV. Provider business mailing address

10152 CREEK RD
PAVILION NY
14525-9715
US

V. Phone/Fax

Practice location:
  • Phone: 585-343-0055
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number000083-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: