Healthcare Provider Details

I. General information

NPI: 1336711027
Provider Name (Legal Business Name): MICHEAL JOSEPH RADLE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2021
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 UNIV BLVD SE
ALBUQUERQUE NM
87106-4327
US

IV. Provider business mailing address

6401 SANTA MONICA AVE NE APT 1025
ALBUQUERQUE NM
87109-4160
US

V. Phone/Fax

Practice location:
  • Phone: 231-340-1657
  • Fax:
Mailing address:
  • Phone: 231-340-1657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: