Healthcare Provider Details

I. General information

NPI: 1710531272
Provider Name (Legal Business Name): JOSEPH H KASUSKA JR. ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19455 DEERFIELD AVE. SUITE 306
LANSDOWNE VA
20176
US

IV. Provider business mailing address

14110 ROCKY VALLEY DR
CENTREVILLE VA
20121
US

V. Phone/Fax

Practice location:
  • Phone: 703-729-5010
  • Fax: 703-729-5833
Mailing address:
  • Phone: 484-467-2889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126003071
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: