MEDICARE: CYNTHIA MALDONADO LAT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	096005237	IL

General Provider Information

NPI Number	:	1063009967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CYNTHIA MALDONADO LAT, ATC

Provider Business Mailing Address
First Line	:	4654 N ELSTON AVE # C1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-4262
Country	:	US
Telephone Number	:	773-677-3412
Fax Number	:

Provider Business Practice Location Address
First Line	:	3852 N CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-3622
Country	:	US
Telephone Number	:	773-355-5407
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/26/2020
Last Update Date	:	12/26/2020

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