=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124659370
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CELIANA VARGAS GUERRA ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2020
-----------------------------------------------------
Last Update Date | 01/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 463 S HOLLENBECK AVE
-----------------------------------------------------
City | COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91723-2999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-974-6020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1108 S BUBBLING WELL RD
-----------------------------------------------------
City | WEST COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91790-5004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-918-9507
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 2000026238
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------