Healthcare Provider Details

I. General information

NPI: 1770303828
Provider Name (Legal Business Name): JORGE MUNDO ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 PETERS RD
LITITZ PA
17543-7685
US

IV. Provider business mailing address

62 BEECH ST
POTTSTOWN PA
19464-5402
US

V. Phone/Fax

Practice location:
  • Phone: 717-627-7675
  • Fax:
Mailing address:
  • Phone: 484-945-3453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT008512
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: