Healthcare Provider Details

I. General information

NPI: 1306898879
Provider Name (Legal Business Name): DAVID A ENSIGN MA, ATC, LAT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3082 CATON FARM RD
JOLIET IL
60435-1455
US

IV. Provider business mailing address

642 DEAMES STREET
PLANO IL
60545
US

V. Phone/Fax

Practice location:
  • Phone: 815-577-9936
  • Fax: 815-577-9938
Mailing address:
  • Phone: 630-273-2721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: