Healthcare Provider Details

I. General information

NPI: 1841754991
Provider Name (Legal Business Name): EVA CERVANTES BS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N UNIVERSITY ST
NORMAL IL
61761-4402
US

IV. Provider business mailing address

4426 TIMBER RIDGE CT
JOLIET IL
60431-1707
US

V. Phone/Fax

Practice location:
  • Phone: 309-438-2111
  • Fax:
Mailing address:
  • Phone: 815-768-9768
  • 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: