Healthcare Provider Details

I. General information

NPI: 1962575829
Provider Name (Legal Business Name): SUZANNE THERESA PACHECO ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1681 CRANSTON ST SUITE A
CRANSTON RI
02920-5000
US

IV. Provider business mailing address

13 CURRAN RD
CUMBERLAND RI
02864-8002
US

V. Phone/Fax

Practice location:
  • Phone: 401-223-0230
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number9596317
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: