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NPI Code Detail

MEDICARE: JESSIE BOLLBACK ATC, LAT

MEDICARE: JESSIE BOLLBACK ATC, 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 Trainer

General Provider Information

NPI Number : 1558746305
Entity Type Code : Individual
Provider Name (Legal Business Name) : JESSIE BOLLBACK ATC, LAT
Provider Business Mailing Address
First Line : 3301 COLLEGE AVE
Second Line :
City : DAVIE
State : FL
Zip : 33314-7796
Country : US
Telephone Number : 954-336-9858
Fax Number :
Provider Business Practice Location Address
First Line : 3301 COLLEGE AVE
Second Line :
City : DAVIE
State : FL
Zip : 33314-7796
Country : US
Telephone Number : 954-336-9858
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/22/2015
Last Update Date : 02/11/2021

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Directions to “ JESSIE BOLLBACK ATC, LAT” Practice Location

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