Provider Demographics
NPI:1417466319
Name:VELASQUEZ, WENDELL JOHN (ATC)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:JOHN
Last Name:VELASQUEZ
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 BANDONI AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LORENZO
Mailing Address - State:CA
Mailing Address - Zip Code:94580-2104
Mailing Address - Country:US
Mailing Address - Phone:510-258-2700
Mailing Address - Fax:
Practice Address - Street 1:18111 NORDHOFF ST
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91330
Practice Address - Country:US
Practice Address - Phone:510-258-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program