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General NPI Number Information
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NPI Number | 1134785728
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Entity Type | Individual
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Provider Name | JORDAN SHIMODA ATC
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Gender | Male
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Dates
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Enumeration Date | 05/20/2019
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Last Update Date | 05/20/2019
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Provider Practice Location Address
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Address Line | 1 PATRIOT PL
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City | FOXBOROUGH
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State | MA
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Zip | 02035-1374
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Country | US
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Telephone | 808-387-9375
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Fax |
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Provider Business Mailing Address
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Address Line | 85 WASHINGTON ST APT 7301
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City | PLAINVILLE
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State | MA
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Zip | 02762-5212
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2150
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License Number State | AL
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2000032108
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License Number State |
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