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General NPI Number Information
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NPI Number | 1184295958
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Entity Type | Individual
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Provider Name | DECEMBER VEGA ATC
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Gender | Female
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Dates
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Enumeration Date | 07/02/2021
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Last Update Date | 03/22/2025
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Provider Practice Location Address
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Address Line | 1111 MACOM DR
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City | DEKALB
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State | IL
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Zip | 60115-8709
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Country | US
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Telephone | 708-289-3892
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Fax |
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Provider Business Mailing Address
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Address Line | 1498 STONEFIELD DR
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City | DEKALB
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State | IL
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Zip | 60115-8903
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Country | US
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Telephone | 708-289-3892
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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