Healthcare Provider Details

I. General information

NPI: 1659334795
Provider Name (Legal Business Name): MR. ROBERT RAYMOND BORYCA III
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12005 248TH AVE.
PLAINFIELD IL
60585
US

IV. Provider business mailing address

2214 PARK RIDGE DR
PLAINFIELD IL
60586-5244
US

V. Phone/Fax

Practice location:
  • Phone: 815-230-4500
  • Fax: 815-254-1796
Mailing address:
  • Phone: 815-577-1088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

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: