MEDICARE: RONALD JEAN AT

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
1	2255A2300X	Athletic Trainer	25MT00135200	NJ

General Provider Information

NPI Number	:	1740500917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONALD JEAN AT

Provider Business Mailing Address
First Line	:	514 JOYCE ST
Second Line	:
City	:	ORANGE
State	:	NJ
Zip	:	07050-1411
Country	:	US
Telephone Number	:	973-672-2214
Fax Number	:	973-672-1320

Provider Business Practice Location Address
First Line	:	514 JOYCE ST
Second Line	:
City	:	ORANGE
State	:	NJ
Zip	:	07050-1411
Country	:	US
Telephone Number	:	973-672-2214
Fax Number	:	973-672-1320

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2010
Last Update Date	:	06/10/2010

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Directions to “ RONALD JEAN AT” Practice Location

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