Healthcare Provider Details

I. General information

NPI: 1801489547
Provider Name (Legal Business Name): KAREN MENDEZ-AVILA ATC, ROT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2021
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 S RANDALL RD
ALGONQUIN IL
60102-5944
US

IV. Provider business mailing address

1522 GOLDEN OAK DR
WOODSTOCK IL
60098-7712
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-9491
  • Fax:
Mailing address:
  • Phone: 815-337-3670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000039576
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: