Healthcare Provider Details

I. General information

NPI: 1902642044
Provider Name (Legal Business Name): JUSTIN EFIRD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7125 NEW SANGER AVE STE 516
WACO TX
76712-4054
US

IV. Provider business mailing address

7125 NEW SANGER AVE STE 516
WACO TX
76712-4054
US

V. Phone/Fax

Practice location:
  • Phone: 281-794-9386
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT5249
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: