Healthcare Provider Details

I. General information

NPI: 1588796924
Provider Name (Legal Business Name): LEE DAVID KUNTZ M.A., ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 EAST CAPITOL ST SE RFK STADIUM, GATE F
WASHINGTON DC
20003
US

IV. Provider business mailing address

3440 26TH ST NW
CANTON OH
44708-2240
US

V. Phone/Fax

Practice location:
  • Phone: 202-731-1609
  • Fax:
Mailing address:
  • Phone: 330-456-0612
  • Fax: 330-456-7947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT 000570
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: