Healthcare Provider Details

I. General information

NPI: 1134148323
Provider Name (Legal Business Name): WILLIAM O KAUTH SR. PH.D, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 AMHERST DR
NORMAL IL
61761-2417
US

IV. Provider business mailing address

510 AMHERST DR
NORMAL IL
61761-2417
US

V. Phone/Fax

Practice location:
  • Phone: 309-452-6486
  • Fax:
Mailing address:
  • Phone:
  • 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: