Provider Demographics
NPI:1164879300
Name:DVORAK, RICK (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:
Last Name:DVORAK
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-0300
Mailing Address - Country:US
Mailing Address - Phone:877-552-2996
Mailing Address - Fax:866-245-8064
Practice Address - Street 1:2717 18TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-4666
Practice Address - Country:US
Practice Address - Phone:262-551-5650
Practice Address - Fax:866-245-8064
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18182255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer