Healthcare Provider Details

I. General information

NPI: 1255865754
Provider Name (Legal Business Name): THOMAS DANNENBERG MAED, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2017
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 S KINGSHIGHWAY ST
SAINT CHARLES MO
63301-1693
US

IV. Provider business mailing address

1015 CORPORATE SQUARE DR STE 220
SAINT LOUIS MO
63132-2938
US

V. Phone/Fax

Practice location:
  • Phone: 618-560-3298
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2014025141
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: