Healthcare Provider Details

I. General information

NPI: 1427640259
Provider Name (Legal Business Name): DILLON MATTHEW HOCK LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4955 FOUNDERS TER APT 210
HOBART WI
54155-7712
US

IV. Provider business mailing address

4955 FOUNDERS TER APT 210
HOBART WI
54155-7712
US

V. Phone/Fax

Practice location:
  • Phone: 630-398-0827
  • Fax:
Mailing address:
  • Phone: 630-398-0827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2394-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: