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NPI Code Detail

MEDICARE: MR. KEVIN NORMAN REISECK ATC, CSCS

MEDICARE: MR. KEVIN NORMAN REISECK ATC, CSCS
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
12255A2300XAthletic TrainerIL

General Provider Information

NPI Number : 1649231838
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. KEVIN NORMAN REISECK ATC, CSCS
Provider Business Mailing Address
First Line : 454 FLORIDA DR
Second Line :
City : EAST ALTON
State : IL
Zip : 62024-1820
Country : US
Telephone Number : 618-259-7322
Fax Number :
Provider Business Practice Location Address
First Line : 1 MEMORIAL DR
Second Line :
City : ALTON
State : IL
Zip : 62002-6722
Country : US
Telephone Number : 618-463-7529
Fax Number : 618-463-7808
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/29/2006
Last Update Date : 07/08/2007

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Directions to “ MR. KEVIN NORMAN REISECK ATC, CSCS” Practice Location

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