Provider Demographics
NPI:1780224246
Name:MELLIN, ALEXANDER C (MS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:C
Last Name:MELLIN
Suffix:
Gender:M
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:COSTELLO ATHLETIC CENTER
Mailing Address - Street 2:275 RIVERSIDE STREET
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:COSTELLO ATHLETIC CENTER
Practice Address - Street 2:275 RIVERSIDE STREET
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854
Practice Address - Country:US
Practice Address - Phone:978-934-2373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20000239442255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000023944OtherNATA BOARD OF CERTIFICATION, CERTIFIED ATHLETIC TRAINER
MA3249-AH-ATOtherCOMMONWEALTH OF MASSACHUSETTS DIVISION OF PROFESSIONAL LICENSURE