Healthcare Provider Details

I. General information

NPI: 1710456199
Provider Name (Legal Business Name): BENEDICTINE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2018
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 COLLEGE RD
LISLE IL
60532-0900
US

IV. Provider business mailing address

5700 COLLEGE RD
LISLE IL
60532-0900
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARK MCHORNEY
Title or Position: ATHLETIC DIRECTOR
Credential:
Phone: 630-829-6150