Healthcare Provider Details

I. General information

NPI: 1366848707
Provider Name (Legal Business Name): JAMES BEDOLLA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 EMMERSON AVE
ITASCA IL
60143-2208
US

IV. Provider business mailing address

229 EMMERSON AVE
ITASCA IL
60143-2208
US

V. Phone/Fax

Practice location:
  • Phone: 847-687-6239
  • Fax:
Mailing address:
  • Phone: 847-687-6239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096003457
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: