Basic Information
| Provider Information | |||||||||
| NPI: | 1457440885 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANBLARICUM | ||||||||
| FirstName: | TROY | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1146 E US HIGHWAY 50 | ||||||||
| Address2: | |||||||||
| City: | NOBLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628682407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6188433855 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1303 W EVERGREEN AVE | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624011619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173423400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.