Healthcare Provider Details

I. General information

NPI: 1699395400
Provider Name (Legal Business Name): HEATHER WRENCH LAT, ATC, CES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13000 VISTA DEL NORTE APT 314
SAN ANTONIO TX
78216-8045
US

IV. Provider business mailing address

PO BOX 34331
SAN ANTONIO TX
78265-4331
US

V. Phone/Fax

Practice location:
  • Phone: 217-621-2466
  • Fax:
Mailing address:
  • Phone: 217-621-2466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT6166
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: