Basic Information
Provider Information | |||||||||
NPI: | 1346394236 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BARNES | ||||||||
FirstName: | KEVIN | ||||||||
MiddleName: | FRANKLIN | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | A.T.C./L. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 S EDWARDS BLVD UNIT 243 | ||||||||
Address2: |   | ||||||||
City: | LAKE GENEVA | ||||||||
State: | WI | ||||||||
PostalCode: | 531474580 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6086284027 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 750 E TERRA COTTA AVE | ||||||||
Address2: |   | ||||||||
City: | CRYSTAL LAKE | ||||||||
State: | IL | ||||||||
PostalCode: | 600143621 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8154550800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/22/2007 | ||||||||
LastUpdateDate: | 01/19/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X |   |   | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.