Healthcare Provider Details

I. General information

NPI: 1083987085
Provider Name (Legal Business Name): MARK HENRICHS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 02/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S BARRINGTON RD
BARRINGTON IL
60010-5276
US

IV. Provider business mailing address

1301 S BARRINGTON RD
BARRINGTON IL
60010-5276
US

V. Phone/Fax

Practice location:
  • Phone: 847-620-4500
  • Fax: 847-620-4515
Mailing address:
  • Phone: 847-620-4500
  • Fax: 847-620-4515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096003228
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: