Provider Demographics
NPI:1902947245
Name:MCINNIS, DAVID HUGH (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:HUGH
Last Name:MCINNIS
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2121 ONEIDA ST
Practice Address - Street 2:SUITE 202
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6544
Practice Address - Country:US
Practice Address - Phone:815-741-4390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL #14492255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer