Individual
JONATHAN DWAIN WIEZOREK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
ATC
Contact information
Practice address
611 WILLOWS AVE, CHATHAM, IL 62629-1717
(217) 415-5806
Mailing address
611 WILLOWS AVE, CHATHAM, IL 62629-1717
(217) 415-5806
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
096002447
IL
Other
Enumeration date
07/18/2012
Last updated
07/18/2012
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