Healthcare Provider Details

I. General information

NPI: 1083137301
Provider Name (Legal Business Name): DAVID MICHAEL FUENTES ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 08/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19455 DEERFIELD AVE STE 312
LANSDOWNE VA
20176-8102
US

IV. Provider business mailing address

3421 DOE RUN CT
HERNDON VA
20171-3358
US

V. Phone/Fax

Practice location:
  • Phone: 703-729-5010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126002757
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: