Healthcare Provider Details

I. General information

NPI: 1780123117
Provider Name (Legal Business Name): ATHLETIC TRAINING AND REHAB CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2017
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BH 9 CALLE QUINTANA SANTA JUANITA
BAYAMON PR
00956-4656
US

IV. Provider business mailing address

BH 9 CALLE QUINTANA SANTA JUANITA
BAYAMON PR
00956-4656
US

V. Phone/Fax

Practice location:
  • Phone: 939-264-1889
  • Fax: 787-395-7972
Mailing address:
  • Phone: 939-264-1889
  • Fax: 787-395-7972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number1923
License Number StatePR

VIII. Authorized Official

Name: MARIO CANALES
Title or Position: PRESIDENT
Credential:
Phone: 787-484-9505