Healthcare Provider Details

I. General information

NPI: 1043640972
Provider Name (Legal Business Name): JUSTIN JOSEPH AGUSTINI LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2013
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 N CHURCH ST
HAZLE TOWNSHIP PA
18202-9307
US

IV. Provider business mailing address

255 MOUNTAIN VIEW DR
NANTICOKE PA
18634-3603
US

V. Phone/Fax

Practice location:
  • Phone: 570-501-1808
  • Fax: 855-635-6308
Mailing address:
  • Phone: 570-814-7073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRTO000178
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: