=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295160984
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLOS DANIEL LUIS ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2013
-----------------------------------------------------
Last Update Date | 09/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12603 STATE ROUTE 143 STE. #8
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62249-1199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-654-4701
-----------------------------------------------------
Fax | 618-654-4739
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12603 STATE ROUTE 143 STE. #8
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62249-1199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-654-4701
-----------------------------------------------------
Fax | 618-654-4739
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 096.003450
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 2013023627
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------