Healthcare Provider Details

I. General information

NPI: 1720007925
Provider Name (Legal Business Name): MARC ROY GAMBLE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12052 S CICERO AVE
ALSIP IL
60803-2313
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 708-489-9940
  • Fax:
Mailing address:
  • Phone: 630-296-2223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number96001909
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: