Healthcare Provider Details

I. General information

NPI: 1942200266
Provider Name (Legal Business Name): JAMES JOHN ALLIVATO JR. LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 EXECUTIVE DR
WILLOW BROOK IL
60527-5603
US

IV. Provider business mailing address

1936 W GRACE ST
CHICAGO IL
60613-2726
US

V. Phone/Fax

Practice location:
  • Phone: 630-455-6630
  • Fax:
Mailing address:
  • Phone: 312-316-5910
  • 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: