Provider Demographics
NPI:1366800476
Name:MEDINA, HUMBERTO JR (ATC, LMT)
Entity type:Individual
Prefix:
First Name:HUMBERTO
Middle Name:
Last Name:MEDINA
Suffix:JR
Gender:M
Credentials:ATC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 HOBART DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-3082
Mailing Address - Country:US
Mailing Address - Phone:630-508-2386
Mailing Address - Fax:
Practice Address - Street 1:721 HOBART DR UNIT A
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-3082
Practice Address - Country:US
Practice Address - Phone:630-508-2386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0014902255A2300X
IL227.014634225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer