1023313194 NPI number — ATHLETIC AND THERAPEUTIC INSTITUTE OF NAPERVILLE, LLC

Table of content: MR. JODY BLAKE WHITE III BA (NPI 1912678707)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023313194 NPI number — ATHLETIC AND THERAPEUTIC INSTITUTE OF NAPERVILLE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATHLETIC AND THERAPEUTIC INSTITUTE OF NAPERVILLE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1023313194
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2222
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1738 165TH ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
HAMMOND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46320-2821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-844-1782
Provider Business Practice Location Address Fax Number:
219-844-1830
Provider Enumeration Date:
01/20/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MCGIVERN
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF COMPLIANCE OFFICER
Authorized Official Telephone Number:
630-296-2222

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DR5600 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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