MEDICARE: MARC REICHLING ATC

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

General Provider Information

NPI Number	:	1790379782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARC REICHLING ATC

Provider Business Mailing Address
First Line	:	430 CHARLES E YOUNG DR WEST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-0001
Country	:	US
Telephone Number	:	310-775-5127
Fax Number	:

Provider Business Practice Location Address
First Line	:	430 CHARLES E YOUNG DR WEST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-0001
Country	:	US
Telephone Number	:	310-775-5127
Fax Number	:

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

Provider Enumeration Date	:	02/22/2021
Last Update Date	:	02/22/2021

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