Provider Demographics
NPI:1104170356
Name:ROLVES, ERIC (ATC)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:ROLVES
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 S FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:ALBERS
Mailing Address - State:IL
Mailing Address - Zip Code:62215-1053
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2346 MASCOUTAH AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-3499
Practice Address - Country:US
Practice Address - Phone:618-277-6282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0008292255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer