Healthcare Provider Details

I. General information

NPI: 1316597396
Provider Name (Legal Business Name): AARON HOBACK ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2019
Last Update Date: 12/31/2020
Certification Date: 12/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CITIZENS BANK WAY
PHILADELPHIA PA
19148-5249
US

IV. Provider business mailing address

2401 COPPER CREEK RD
MARYVILLE IL
62062-5666
US

V. Phone/Fax

Practice location:
  • Phone: 618-954-8435
  • Fax:
Mailing address:
  • Phone: 618-954-8435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number110502001
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: