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General NPI Number Information
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NPI Number | 1861078032
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Entity Type | Organization
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Legal Business Name | ATHLETAMD LLC
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Dates
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Enumeration Date | 03/19/2021
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Last Update Date | 03/19/2021
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Provider Practice Location Address
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Address Line | 12621 NW 8TH COURT
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City | CORAL SPRINGS
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State | FL
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Zip | 33071
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Country | US
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Telephone | 954-543-1760
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Fax | 954-752-7845
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Provider Business Mailing Address
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Address Line | 1440 CORAL RIDGE DR #121
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City | CORAL SPRINGS
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State | FL
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Zip | 33071
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Country | US
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Telephone | 954-543-1760
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Fax | 954-752-7845
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Authorized Official
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Title or Position | MD / OWNER
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Name | MRS. EDNA LILLIAN TELLO
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Credential | MD
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Telephone | 954-632-2791
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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