Healthcare Provider Details

I. General information

NPI: 1154394393
Provider Name (Legal Business Name): WILLIAM ALLEN KAUTH ED.D. , ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 E. EMERSON ST.
BLOOMINGTON IL
61702-2900
US

IV. Provider business mailing address

1 LAKEVIEW PT
BLOOMINGTON IL
61701-7818
US

V. Phone/Fax

Practice location:
  • Phone: 309-556-3601
  • Fax:
Mailing address:
  • Phone: 309-823-9189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: