=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689050445
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS AGUILERA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2015
-----------------------------------------------------
Last Update Date | 08/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 CEDAR AVE
-----------------------------------------------------
City | WEST LONG BRANCH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07764-1804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-263-4423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34 BRANKO RD
-----------------------------------------------------
City | BERKELEY HEIGHTS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07922-2324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 25MT00209800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------