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General NPI Number Information
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NPI Number | 1205113917
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Entity Type | Individual
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Provider Name | JUSTIN SEGOTTA ATC
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Gender | Male
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Dates
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Enumeration Date | 11/08/2011
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Last Update Date | 06/24/2019
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Provider Practice Location Address
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Address Line | 15459 W BELL RD STE 107
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City | SURPRISE
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State | AZ
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Zip | 85374-2475
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Country | US
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Telephone | 623-432-9965
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Fax |
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Provider Business Mailing Address
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Address Line | 15459 W BELL RD STE 107
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City | SURPRISE
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State | AZ
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Zip | 85374-2475
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Country | US
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Telephone | 623-432-9965
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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 | 1279
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License Number State | AZ
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