Healthcare Provider Details

I. General information

NPI: 1710584792
Provider Name (Legal Business Name): MELVIN ENDERES ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2020
Last Update Date: 11/27/2023
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42678 FRONTIER DR
BRAMBLETON VA
20148-7207
US

IV. Provider business mailing address

42678 FRONTIER DR
BRAMBLETON VA
20148-7207
US

V. Phone/Fax

Practice location:
  • Phone: 571-888-0852
  • Fax:
Mailing address:
  • Phone: 571-888-0852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: