Basic Information
| Provider Information | |||||||||
| NPI: | 1770591919 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEVILLE | ||||||||
| FirstName: | NATHANIEL | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MAED, ATC/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 517 LIVINGSTON DR | ||||||||
| Address2: | |||||||||
| City: | NEW LENOX | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604511626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082503272 | ||||||||
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| Practice Location | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962222 | ||||||||
| FaxNumber: | 2054823605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 02/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 096.002404 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.