=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497627228
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANIAH JAEL ORTIZ MAT, LAT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2025
-----------------------------------------------------
Last Update Date | 09/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3133 GOOD SHEPHERD WAY
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75605-7921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-323-6500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 E MARSHALL AVE
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75601-5580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-351-2000
-----------------------------------------------------
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 | AT10217
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------