Healthcare Provider Details

I. General information

NPI: 1659344240
Provider Name (Legal Business Name): LEE ANN PRICE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 LINCOLN AVE 2220 LANTZ
CHARLESTON IL
61920-3011
US

IV. Provider business mailing address

10875 E COUNTY ROAD 600N
MATTOON IL
61938-8521
US

V. Phone/Fax

Practice location:
  • Phone: 217-581-7615
  • Fax:
Mailing address:
  • Phone: 217-549-0439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096-0000892
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: