Provider Demographics
NPI:1386635647
Name:NATIONAL ATHLETIC ALLIANCE, INC.
Entity Type:Organization
Organization Name:NATIONAL ATHLETIC ALLIANCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:VENTRICELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-636-9053
Mailing Address - Street 1:21320 N TWO HAWK RD
Mailing Address - Street 2:
Mailing Address - City:PAULDEN
Mailing Address - State:AZ
Mailing Address - Zip Code:86334-4329
Mailing Address - Country:US
Mailing Address - Phone:928-636-9053
Mailing Address - Fax:
Practice Address - Street 1:410 MOREHOUSE RD
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:CT
Practice Address - Zip Code:06612-1638
Practice Address - Country:US
Practice Address - Phone:928-636-9053
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2008-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005593261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy