=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972291227
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHOENIX SIANNI TOPETE BS, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2023
-----------------------------------------------------
Last Update Date | 04/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11155 ALMOND AVE
-----------------------------------------------------
City | FONTANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92337-7113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-357-5900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12015 SPARTAN LN
-----------------------------------------------------
City | FONTANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92337-9071
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------