Healthcare Provider Details

I. General information

NPI: 1598317521
Provider Name (Legal Business Name): ALDEN FONTANA ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 IRVING SCHOTTENSTEIN DR
COLUMBUS OH
43210-1069
US

IV. Provider business mailing address

42 FRANKLIN ST
DUXBURY MA
02332-3204
US

V. Phone/Fax

Practice location:
  • Phone: 614-292-1165
  • Fax:
Mailing address:
  • Phone: 781-291-0447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3243
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT5959
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: