Healthcare Provider Details

I. General information

NPI: 1922125905
Provider Name (Legal Business Name): NEAL FREDERICK SAND ATC., CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 PATRICK GYM SPEAR STREET
BURLINGTON VT
05405-0001
US

IV. Provider business mailing address

71 ALLEN DR
MILTON VT
05468-3872
US

V. Phone/Fax

Practice location:
  • Phone: 802-656-9573
  • Fax: 802-656-9578
Mailing address:
  • Phone: 802-893-6724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1040000068
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: