Healthcare Provider Details

I. General information

NPI: 1619635869
Provider Name (Legal Business Name): VANESSA CHAVEZ MAT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 01/02/2023
Certification Date: 01/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 KEDZIE AVE
FLOSSMOOR IL
60422-2248
US

IV. Provider business mailing address

11330 S AVENUE M
CHICAGO IL
60617-7056
US

V. Phone/Fax

Practice location:
  • Phone: 708-799-3000
  • Fax:
Mailing address:
  • Phone: 773-470-5669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096005619
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: