Healthcare Provider Details

I. General information

NPI: 1487135877
Provider Name (Legal Business Name): MR. AUSTIN MENNING
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2018
Last Update Date: 08/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3025 CAMELS HUMP RD.
HUNTINGTON VT
05462
US

IV. Provider business mailing address

PO BOX 23
HUNTINGTON VT
05462-0023
US

V. Phone/Fax

Practice location:
  • Phone: 802-434-6056
  • Fax:
Mailing address:
  • Phone: 180-243-4605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: