Healthcare Provider Details

I. General information

NPI: 1093554883
Provider Name (Legal Business Name): DAVID CLAYTON GRAEFF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 W 71ST ST
BRIDGEVIEW IL
60455-1051
US

IV. Provider business mailing address

1320 MC DOWELL RD APT 202
NAPERVILLE IL
60563-1178
US

V. Phone/Fax

Practice location:
  • Phone: 815-347-8262
  • Fax:
Mailing address:
  • Phone: 815-347-8262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096002356
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: