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General NPI Number Information
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NPI Number | 1740587567
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Entity Type | Individual
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Provider Name | MARK H NILLES ATC, CSCS, CES, PES
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Gender | Male
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Dates
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Enumeration Date | 02/14/2011
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Last Update Date | 04/04/2016
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Provider Practice Location Address
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Address Line | 1221 N HIGHLAND AVE
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City | AURORA
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State | IL
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Zip | 60506-1404
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Country | US
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Telephone | 630-264-8966
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Fax |
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Provider Business Mailing Address
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Address Line | 1377 HARTSBURG LN
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City | NORTH AURORA
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State | IL
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Zip | 60542-8953
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Country | US
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Telephone | 630-715-1026
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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 | 096001654
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License Number State | IL
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