Healthcare Provider Details

I. General information

NPI: 1649556820
Provider Name (Legal Business Name): JEREMY JOSEPH HERNIMAN ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3170 WEST ST
CANANDAIGUA NY
14424-1712
US

IV. Provider business mailing address

5770 OATFIELD DR
FARMINGTON NY
14425-9368
US

V. Phone/Fax

Practice location:
  • Phone: 585-396-6700
  • Fax:
Mailing address:
  • Phone: 269-806-3009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number001967-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: