Healthcare Provider Details

I. General information

NPI: 1023023512
Provider Name (Legal Business Name): SARAH ANN SYDOR ATC/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2122 N 27TH ST
DECATUR IL
62526-2191
US

IV. Provider business mailing address

1001 POMONA DR
CHAMPAIGN IL
61822-1859
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-4975
  • Fax:
Mailing address:
  • Phone: 217-418-9467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number815
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: