Provider Demographics
NPI:1013315092
Name:LACROSS, ZACH (ATC)
Entity Type:Individual
Prefix:
First Name:ZACH
Middle Name:
Last Name:LACROSS
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Gender:M
Credentials:ATC
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Other - Last Name:
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Mailing Address - Street 1:1490 DOUGLAS DR
Mailing Address - Street 2:LINGLE HALL 118, MC 6620
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-4332
Mailing Address - Country:US
Mailing Address - Phone:618-453-4163
Mailing Address - Fax:618-453-4173
Practice Address - Street 1:1490 DOUGLAS DR
Practice Address - Street 2:LINGLE HALL 118, MC 6620
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-4332
Practice Address - Country:US
Practice Address - Phone:618-453-4163
Practice Address - Fax:618-453-4173
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL096.0034152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer