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General NPI Number Information
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NPI Number | 1821619768
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Entity Type | Individual
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Provider Name | MICHAEL JAMES GUDDENDORF ATC
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Gender | Male
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Dates
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Enumeration Date | 05/01/2020
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Last Update Date | 05/01/2020
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Provider Practice Location Address
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Address Line | 2122 N 27TH ST
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City | DECATUR
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State | IL
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Zip | 62526-2191
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Country | US
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Telephone | 217-876-4249
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Fax |
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Provider Business Mailing Address
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Address Line | 1276 OAKLEAF CT
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City | AURORA
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State | IL
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Zip | 60506-1676
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Country | US
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Telephone |
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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 | 096004843
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License Number State | IL
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