Healthcare Provider Details

I. General information

NPI: 1013638956
Provider Name (Legal Business Name): AUSTIN WIELGOSZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2022
Last Update Date: 09/08/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12337 SOUTH, ILLINOIS ROUTE 59 SUITE 119
PLAINFIELD IL
60585
US

IV. Provider business mailing address

24157 S EDWIN DR
CHANNAHON IL
60410-5210
US

V. Phone/Fax

Practice location:
  • Phone: 815-267-6263
  • 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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: