=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366923351
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VAISHWAN DAVE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2018
-----------------------------------------------------
Last Update Date | 08/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 22ND ST NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20052-0055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-899-4756
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 DAVENPORT RD
-----------------------------------------------------
City | WEST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06110-2128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-899-4756
-----------------------------------------------------
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 | 2000031799
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------