Healthcare Provider Details

I. General information

NPI: 1083862841
Provider Name (Legal Business Name): MATTHEW SCOTT REPA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2008
Last Update Date: 09/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 RAVINE WAY SUITE 100
GLENVIEW IL
60025-7645
US

IV. Provider business mailing address

9326 KEDVALE AVE
SKOKIE IL
60076-1421
US

V. Phone/Fax

Practice location:
  • Phone: 847-724-4791
  • Fax:
Mailing address:
  • Phone: 847-269-9326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.002602
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: