Healthcare Provider Details

I. General information

NPI: 1699767673
Provider Name (Legal Business Name): DINO LAURENZI JR. L-ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6308 8TH AVE SUITE 501
KENOSHA WI
53143-5031
US

IV. Provider business mailing address

8005 103RD AVE
PLEASANT PRAIRIE WI
53158-2050
US

V. Phone/Fax

Practice location:
  • Phone: 262-656-3280
  • Fax:
Mailing address:
  • Phone: 262-697-1759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number35
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: