Provider Demographics
NPI:1467195792
Name:KUNTZ, MITCHELL JACK (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:JACK
Last Name:KUNTZ
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 MAIN ST NW APT 2
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1991
Mailing Address - Country:US
Mailing Address - Phone:309-840-2011
Mailing Address - Fax:
Practice Address - Street 1:443 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-1096
Practice Address - Country:US
Practice Address - Phone:815-928-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
20000050506Other2255A2300X - SPECIALIST/TECHNOLOGIST - ATHLETIC TRAINER