Healthcare Provider Details

I. General information

NPI: 1154396851
Provider Name (Legal Business Name): ANDREW S LLAGUNO MSED ATC CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 KEANEY RD SUITE ONE
KINGSTON RI
02881-1111
US

IV. Provider business mailing address

97C SAND PLAIN RD
CHARLESTOWN RI
02813-3837
US

V. Phone/Fax

Practice location:
  • Phone: 401-874-5230
  • Fax:
Mailing address:
  • Phone: 401-364-8066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number139
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: