Provider Demographics
NPI:1467476366
Name:KLOBNAK, MICHAEL WARREN JR (ATC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WARREN
Last Name:KLOBNAK
Suffix:JR
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 1:2578 PORTAGE AVE
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-5031
Mailing Address - Country:US
Mailing Address - Phone:847-526-3103
Mailing Address - Fax:
Practice Address - Street 1:300 CHURCH ST
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-1553
Practice Address - Country:US
Practice Address - Phone:847-540-4797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL960021602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer