Healthcare Provider Details

I. General information

NPI: 1962047928
Provider Name (Legal Business Name): RACHEL MCDANIELS ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 JOE ABBOTT WAY
MARION IL
62959-4649
US

IV. Provider business mailing address

205 NOAH LN
CARTERVILLE IL
62918-6135
US

V. Phone/Fax

Practice location:
  • Phone: 618-993-6237
  • Fax:
Mailing address:
  • Phone: 618-967-5836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.004505
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: