MEDICARE: KELLY DANIELAK ATC, LAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	096.005308	IL

General Provider Information

NPI Number	:	1063085983
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY DANIELAK ATC, LAT

Provider Business Mailing Address
First Line	:	8429 LATROBE AVE
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60077-2155
Country	:	US
Telephone Number	:	847-946-7732
Fax Number	:

Provider Business Practice Location Address
First Line	:	8429 LATROBE AVE
Second Line	:
City	:	SKOKIE
State	:	IL
Zip	:	60077-2155
Country	:	US
Telephone Number	:	847-946-7732
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2021
Last Update Date	:	07/19/2021

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