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General NPI Number Information
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NPI Number | 1487190047
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Entity Type | Individual
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Provider Name | MICHAEL THEILE MS, LAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 01/06/2017
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Last Update Date | 01/13/2022
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Provider Practice Location Address
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Address Line | 15754 N BULLARD AVE
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City | SURPRISE
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State | AZ
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Zip | 85374-8839
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Country | US
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Telephone | 414-333-3416
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Fax |
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Provider Business Mailing Address
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Address Line | 4612 W BERKSHIRE DR
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City | FRANKLIN
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State | WI
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Zip | 53132-8172
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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