=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346207008
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH ANTHONY PORCELLO ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 96 BELMOHR ST
-----------------------------------------------------
City | BELLEVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07109-2202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-450-1648
-----------------------------------------------------
Fax | 973-751-3898
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 549 POMPTON AVE
-----------------------------------------------------
City | CEDAR GROVE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07009-1720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-450-1648
-----------------------------------------------------
Fax | 973-751-3898
-----------------------------------------------------
=====================================================
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 | 25MT00065100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------