=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265637177
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILTEY RUSSELL KENDLE ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 228 17TH AVE NW
-----------------------------------------------------
City | GREAT FALLS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59404-1807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-268-6223
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 118 WOODLAND ESTATES RD
-----------------------------------------------------
City | GREAT FALLS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59404-6405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-453-9030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------