1053847475 NPI number — JASYN SCOTT CHIDESTER A.T.C.

Table of content: JASYN SCOTT CHIDESTER A.T.C. (NPI 1053847475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053847475 NPI number — JASYN SCOTT CHIDESTER A.T.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHIDESTER
Provider First Name:
JASYN
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
A.T.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053847475
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4003 CHEENEY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA CLARA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95054-2522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-504-0048
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 EL CAMINO REAL
Provider Second Line Business Practice Location Address:
SUITE M384, OFFICE 229
Provider Business Practice Location Address City Name:
PALO ALTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-885-6300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2000025880 . This is a "BOC CERTIFIED ATHLETIC TRAINER" identifier . This identifiers is of the category "OTHER".




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