1467195792 NPI number — MITCHELL JACK KUNTZ MS, LAT, ATC

Table of content: HEIDI MARIE KELLER (NPI 1609365139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467195792 NPI number — MITCHELL JACK KUNTZ MS, LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUNTZ
Provider First Name:
MITCHELL
Provider Middle Name:
JACK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, LAT, ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467195792
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
209 MAIN ST NW APT 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOURBONNAIS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60914-1991
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-840-2011
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
443 N MAPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANTENO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60950-1096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-928-7100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 20000050506 . This is a "2255A2300X - SPECIALIST/TECHNOLOGIST - ATHLETIC TRAINER" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com