Provider Demographics
NPI:1063950277
Name:GORETH, WILLIAM
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:GORETH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48W930 IL ROUTE 64
Mailing Address - Street 2:
Mailing Address - City:MAPLE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60151-8581
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1311 W LINCOLN HWY
Practice Address - Street 2:APT Q
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-2970
Practice Address - Country:US
Practice Address - Phone:847-702-4171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer