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General NPI Number Information
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NPI Number | 1174991210
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Entity Type | Individual
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Provider Name | TARA VANDENBOSCH MS, ATC, CSCS, LAT
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Gender | Female
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Dates
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Enumeration Date | 09/07/2015
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Last Update Date | 09/07/2015
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Provider Practice Location Address
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Address Line | 11300 NE 2ND AVE
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City | MIAMI SHORES
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State | FL
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Zip | 33161-6628
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Country | US
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Telephone | 308-899-3572
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Fax |
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Provider Business Mailing Address
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Address Line | 5725 GARFIELD ST
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City | HOLLYWOOD
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State | FL
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Zip | 33021-5150
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Country | US
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Telephone | 860-912-9745
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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 | AL4125
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License Number State | FL
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