=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588357982
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MITCHELL KENNEDY ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2023
-----------------------------------------------------
Last Update Date | 05/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2111 MIDLANDS CT
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-3125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-758-0000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1480 CAMBRIA DR UNIT 4
-----------------------------------------------------
City | DEKALB
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60115-1083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-901-2422
-----------------------------------------------------
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 | 096004291
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------