Healthcare Provider Details

I. General information

NPI: 1871576330
Provider Name (Legal Business Name): ALEXANDRIA ROSE URGO ATC, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 W DIVERSEY PKWY
CHICAGO IL
60614-1207
US

IV. Provider business mailing address

7005 99TH ST #3
CHICAGO RIDGE IL
60415-1152
US

V. Phone/Fax

Practice location:
  • Phone: 773-549-2520
  • Fax:
Mailing address:
  • Phone: 773-218-8535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: