Healthcare Provider Details

I. General information

NPI: 1134897705
Provider Name (Legal Business Name): NATHAN SCOTT LANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 W LINCOLN HWY
DEKALB IL
60115-3989
US

IV. Provider business mailing address

118 AUGUSTA AVE APT 13
DEKALB IL
60115-3166
US

V. Phone/Fax

Practice location:
  • Phone: 929-317-5252
  • Fax:
Mailing address:
  • Phone: 929-317-5252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: