Healthcare Provider Details

I. General information

NPI: 1386075687
Provider Name (Legal Business Name): TODD LAZENBY MA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 12/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

953 DANBY RD G68 HILL CENTER
ITHACA NY
14850-7000
US

IV. Provider business mailing address

953 DANBY RD G68 HILL CENTER
ITHACA NY
14850-7000
US

V. Phone/Fax

Practice location:
  • Phone: 607-274-1717
  • Fax:
Mailing address:
  • Phone: 607-274-1717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number001573-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: