Provider Demographics
NPI:1437556222
Name:WACHOWIAK, KEVIN (LAT/ATC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:WACHOWIAK
Suffix:
Gender:M
Credentials:LAT/ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 N SILVERLEAF BLVD
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-1602
Mailing Address - Country:US
Mailing Address - Phone:630-877-2419
Mailing Address - Fax:
Practice Address - Street 1:390 N SILVERLEAF BLVD
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-1602
Practice Address - Country:US
Practice Address - Phone:630-877-2419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-23
Last Update Date:2014-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0036572255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer