=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770303828
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORGE MUNDO ATC, LAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2024
-----------------------------------------------------
Last Update Date | 10/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 51 PETERS RD
-----------------------------------------------------
City | LITITZ
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17543-7685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-627-7675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 62 BEECH ST
-----------------------------------------------------
City | POTTSTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19464-5402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-945-3453
-----------------------------------------------------
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 | RT008512
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------