=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447058862
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZACHARY SEAN HARRIS LAT, MS, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2025
-----------------------------------------------------
Last Update Date | 03/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 UNIVERSITY PKWY
-----------------------------------------------------
City | ROMEOVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60446-1832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-231-7741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16146 W SAND LILLY ST
-----------------------------------------------------
City | LOCKPORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60441-4138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-231-7741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 2000056526
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------