Provider Demographics
NPI:1336339324
Name:MARDIS, ALLEN WAYNE (ATC)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:WAYNE
Last Name:MARDIS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1490 DOUGLAS DR
Mailing Address - Street 2:MC 6620
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-4332
Mailing Address - Country:US
Mailing Address - Phone:570-492-1784
Mailing Address - Fax:618-453-4173
Practice Address - Street 1:1490 DOUGLAS DR
Practice Address - Street 2:MC 6620
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-4332
Practice Address - Country:US
Practice Address - Phone:570-492-1784
Practice Address - Fax:618-453-4173
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2013-11-07
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer