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NPI Code Detail

MEDICARE: JUSTIN DAVID WHITEHOUSE M.A., ATC

MEDICARE: JUSTIN DAVID WHITEHOUSE M.A., 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
12255A2300XAthletic Trainer96002241IL

General Provider Information

NPI Number : 1730250861
Entity Type Code : Individual
Provider Name (Legal Business Name) : JUSTIN DAVID WHITEHOUSE M.A., ATC
Provider Business Mailing Address
First Line : 315 HOBBLE BUSH DR
Second Line :
City : LAKE ZURICH
State : IL
Zip : 60047-2739
Country : US
Telephone Number : 847-540-8770
Fax Number :
Provider Business Practice Location Address
First Line : 1802 N 64TH ST
Second Line :
City : PHOENIX
State : AZ
Zip : 85008-3400
Country : US
Telephone Number : 480-949-5951
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/12/2006
Last Update Date : 07/08/2007

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