Healthcare Provider Details

I. General information

NPI: 1679073282
Provider Name (Legal Business Name): KURT EUGENE THIELE III M.A., ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 02/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CAVALIER CIR
FOREST VA
24551-2206
US

IV. Provider business mailing address

1055 COLUMN WAY APT 203
FOREST VA
24551-1885
US

V. Phone/Fax

Practice location:
  • Phone: 540-680-9732
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126002622
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: