Provider Demographics
NPI:1144597907
Name:JUANES, ALISE MARIE (ATC)
Entity Type:Individual
Prefix:MRS
First Name:ALISE
Middle Name:MARIE
Last Name:JUANES
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:55 FAIR DR
Mailing Address - Street 2:ATTN: ATHLETICS
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-6520
Mailing Address - Country:US
Mailing Address - Phone:714-556-3610
Mailing Address - Fax:714-662-5259
Practice Address - Street 1:55 FAIR DR
Practice Address - Street 2:ATTN: ATHLETICS
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-6520
Practice Address - Country:US
Practice Address - Phone:714-556-3610
Practice Address - Fax:714-662-5259
Is Sole Proprietor?:No
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer