Basic Information
| Provider Information | |||||||||
| NPI: | 1558741520 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWENSON | ||||||||
| FirstName: | JUSTIN | ||||||||
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| Credential: | L.A.T., A.T.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1130 N CHURCH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363752300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1130 N CHURCH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4145109634 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2015 | ||||||||
| LastUpdateDate: | 06/04/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | LAT-2468 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.