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NPI Code Detail

MEDICARE: TARA VANDENBOSCH MS, ATC, CSCS, LAT

MEDICARE: TARA VANDENBOSCH MS, ATC, CSCS, LAT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic TrainerAL4125FL

General Provider Information

NPI Number : 1174991210
Entity Type Code : Individual
Provider Name (Legal Business Name) : TARA VANDENBOSCH MS, ATC, CSCS, LAT
Provider Business Mailing Address
First Line : 5725 GARFIELD ST
Second Line :
City : HOLLYWOOD
State : FL
Zip : 33021-5150
Country : US
Telephone Number : 860-912-9745
Fax Number :
Provider Business Practice Location Address
First Line : 11300 NE 2ND AVE
Second Line :
City : MIAMI SHORES
State : FL
Zip : 33161-6628
Country : US
Telephone Number : 308-899-3572
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/07/2015
Last Update Date : 09/07/2015

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