Healthcare Provider Details

I. General information

NPI: 1952880023
Provider Name (Legal Business Name): KENNETH DILDINE JR. ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 TOM GINNEVER AVE
O FALLON MO
63366-4406
US

IV. Provider business mailing address

25 DEER RUN TRL
NEW FLORENCE MO
63363-3519
US

V. Phone/Fax

Practice location:
  • Phone: 636-359-8884
  • Fax:
Mailing address:
  • Phone: 636-359-8884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2018024370
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: