=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932517919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDREW WILLSON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2014
-----------------------------------------------------
Last Update Date | 07/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 915 W CARMEN AVE APT 506
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-3261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-598-1758
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 915 W CARMEN AVE APT 506
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-3261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ATHLETIC TRAINER
-----------------------------------------------------
Name | ANDREW WILLSON
-----------------------------------------------------
Credential | ATC
-----------------------------------------------------
Telephone | 269-598-1758
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 096.003776
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------