Healthcare Provider Details

I. General information

NPI: 1841426285
Provider Name (Legal Business Name): LUIS DEJESUS JR. MA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2009
Last Update Date: 05/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 EAST WASHINGTON ST.
MEDINA OH
44256
US

IV. Provider business mailing address

345 SPRINGBROOK DR. #202
MEDINA OH
44256
US

V. Phone/Fax

Practice location:
  • Phone: 330-725-1000
  • Fax: 330-721-4913
Mailing address:
  • Phone: 724-734-1331
  • 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: