Healthcare Provider Details

I. General information

NPI: 1821396722
Provider Name (Legal Business Name): DOUGLAS A WEST ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 03/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E COLLEGE AVE
BLOOMINGTON IL
61704-2101
US

IV. Provider business mailing address

1205 N LIVINGSTON ST
BLOOMINGTON IL
61701-1534
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-3038
  • Fax: 309-664-3119
Mailing address:
  • Phone: 309-838-3640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096003032
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: