Healthcare Provider Details

I. General information

NPI: 1841693652
Provider Name (Legal Business Name): CAITLIN KEROACK ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 10/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HORTON FIELDHOUSE CAMPUS BOX 7130
NORMAL IL
61790-7130
US

IV. Provider business mailing address

3008 CAMDEN CIR
WILLIAMSBURG VA
23185-8713
US

V. Phone/Fax

Practice location:
  • Phone: 309-438-3340
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096003548
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: