Healthcare Provider Details

I. General information

NPI: 1013450428
Provider Name (Legal Business Name): JAKE BUHMANN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2016
Last Update Date: 12/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 FESTIVAL CT
ELGIN IL
60120-6406
US

IV. Provider business mailing address

159 FESTIVAL CT
ELGIN IL
60120-6406
US

V. Phone/Fax

Practice location:
  • Phone: 630-200-5568
  • Fax:
Mailing address:
  • Phone:
  • 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: