MEDICARE: SAVITRIA NICOLE WILLIAMS ATC, L.A.T

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		IL

General Provider Information

NPI Number	:	1164485561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAVITRIA NICOLE WILLIAMS ATC, L.A.T

Provider Business Mailing Address
First Line	:	1691 222ND PL
Second Line	:
City	:	SAUK VILLAGE
State	:	IL
Zip	:	60411-4939
Country	:	US
Telephone Number	:	708-769-6598
Fax Number	:

Provider Business Practice Location Address
First Line	:	2499 E JOLIET HWY
Second Line	:	UNIT 112
City	:	NEW LENOX
State	:	IL
Zip	:	60451-2592
Country	:	US
Telephone Number	:	815-462-9420
Fax Number	:

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

Provider Enumeration Date	:	04/08/2006
Last Update Date	:	07/08/2007

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