Healthcare Provider Details

I. General information

NPI: 1366800476
Provider Name (Legal Business Name): HUMBERTO MEDINA JR. ATC, LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2016
Last Update Date: 02/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 HOBART DR UNIT A
SOUTH ELGIN IL
60177-3082
US

IV. Provider business mailing address

721 HOBART DR UNIT A
SOUTH ELGIN IL
60177-3082
US

V. Phone/Fax

Practice location:
  • Phone: 630-508-2386
  • Fax:
Mailing address:
  • Phone: 630-508-2386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.001490
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.014634
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: