Healthcare Provider Details

I. General information

NPI: 1083609648
Provider Name (Legal Business Name): ERIC MICHAEL STREETER MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 04/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 S NEIL ST
CHAMPAIGN IL
61820-7220
US

IV. Provider business mailing address

2204 E TRAILSIDE DR N
MAHOMET IL
61853-8512
US

V. Phone/Fax

Practice location:
  • Phone: 217-352-3330
  • Fax:
Mailing address:
  • Phone: 217-622-7175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096-001764
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: