Healthcare Provider Details

I. General information

NPI: 1679088314
Provider Name (Legal Business Name): IAN C HURLBURT M.S, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2017
Last Update Date: 12/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S MAIN ST
CANANDAIGUA NY
14424-2126
US

IV. Provider business mailing address

4554 STATE ROUTE 364
CANANDAIGUA NY
14424-9754
US

V. Phone/Fax

Practice location:
  • Phone: 585-455-8350
  • Fax: 585-455-8350
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: