Provider Demographics
NPI:1225597180
Name:KINGDON, JOSEPH B (ATC/L)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:B
Last Name:KINGDON
Suffix:
Gender:M
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 SEARLE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2866
Mailing Address - Country:US
Mailing Address - Phone:630-742-8851
Mailing Address - Fax:
Practice Address - Street 1:1505 EASTLAND DR STE 220
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7906
Practice Address - Country:US
Practice Address - Phone:309-662-2278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0034962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer