=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487155248
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDRES TOMAS ALMERAYA ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2018
-----------------------------------------------------
Last Update Date | 02/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2110 HILLSIDE RD #1078R
-----------------------------------------------------
City | STORRS
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06269-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-486-0002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 MAYFLOWER ST
-----------------------------------------------------
City | WEST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06110-1421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-601-3482
-----------------------------------------------------
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 | 1169
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------