Healthcare Provider Details

I. General information

NPI: 1609142736
Provider Name (Legal Business Name): KELE A CIOFLEC MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1704 EASTLAND DR STE 15
BLOOMINGTON IL
61704-3580
US

IV. Provider business mailing address

1206 S CLAYTON ST
BLOOMINGTON IL
61701-6817
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-7766
  • Fax:
Mailing address:
  • Phone: 571-334-2380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.002965
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: