MEDICARE: ATHLETIC &THERAPEUTIC INSTITUTE OF BOURBONNAIS LLC

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1952951808
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATHLETIC &THERAPEUTIC INSTITUTE OF BOURBONNAIS LLC

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:	630-296-2222
Fax Number	:

Provider Business Practice Location Address
First Line	:	1275 N CONVENT ST STE 3
Second Line	:
City	:	BOURBONNAIS
State	:	IL
Zip	:	60914-8211
Country	:	US
Telephone Number	:	815-936-1855
Fax Number	:	815-936-6097

Authorized Official
Title or Position	:	COO
Name	:	WADE MEYER
Credential	:	COO
Telephone Number	:	630-296-2223

Provider Enumeration Date	:	09/12/2019
Last Update Date	:	09/12/2019

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