=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477348928
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LANCE AARON WENZEL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2025
-----------------------------------------------------
Last Update Date | 04/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 E CALUMET ST
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62801-6511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-532-7391
-----------------------------------------------------
Fax | 618-532-8952
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2884 E FOX RD
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62801-8807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-780-0430
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------