Provider Demographics
NPI:1275501587
Name:FLORENCE, MARK ANDREW (ATC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANDREW
Last Name:FLORENCE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 FAIRWAY DR
Mailing Address - Street 2:APT. 301
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8717
Mailing Address - Country:US
Mailing Address - Phone:630-428-0754
Mailing Address - Fax:
Practice Address - Street 1:2360 95TH ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-8934
Practice Address - Country:US
Practice Address - Phone:630-428-6398
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer