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

Table of content: MITCHELL JACK KUNTZ MS, LAT, ATC (NPI 1467195792)

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".




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