MEDICARE: MR. JUSTIN A SJOVALL M.ED, ATC

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	:	1205805017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUSTIN A SJOVALL M.ED, ATC

Provider Business Mailing Address
First Line	:	3118 N CLIFTON AVE
Second Line	:	APT. 2F
City	:	CHICAGO
State	:	IL
Zip	:	60657-3370
Country	:	US
Telephone Number	:	773-244-5682
Fax Number	:

Provider Business Practice Location Address
First Line	:	3225 W FOSTER AVE
Second Line	:	BOX 25
City	:	CHICAGO
State	:	IL
Zip	:	60625-4823
Country	:	US
Telephone Number	:	773-244-5682
Fax Number	:

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

Provider Enumeration Date	:	03/15/2006
Last Update Date	:	07/08/2007

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