=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629427893
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTIANA ORGERA ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2016
-----------------------------------------------------
Last Update Date | 06/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 KINGS HWY APT A
-----------------------------------------------------
City | SWEDESBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08085-1205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-925-4346
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 KINGS HWY APT A
-----------------------------------------------------
City | SWEDESBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08085-1205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-925-4346
-----------------------------------------------------
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 | 073811247159934
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------