Healthcare Provider Details

I. General information

NPI: 1467753574
Provider Name (Legal Business Name): NATHAN A VANRADEN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 COLLEGE RD
LISLE IL
60532-0900
US

IV. Provider business mailing address

14421 W MELBOURNE PL
LOCKPORT IL
60441-6016
US

V. Phone/Fax

Practice location:
  • Phone: 630-829-6154
  • Fax: 630-839-3696
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.002607
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: