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General NPI Number Information
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NPI Number | 1679073282
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Entity Type | Individual
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Provider Name | KURT EUGENE THIELE III M.A., ATC, LAT
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Gender | Male
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Dates
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Enumeration Date | 02/20/2018
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Last Update Date | 02/20/2018
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Provider Practice Location Address
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Address Line | 1 CAVALIER CIR
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City | FOREST
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State | VA
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Zip | 24551-2206
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Country | US
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Telephone | 540-680-9732
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Fax |
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Provider Business Mailing Address
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Address Line | 1055 COLUMN WAY APT 203
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City | FOREST
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State | VA
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Zip | 24551-1885
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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 | 0126002622
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License Number State | VA
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Taxonomy #2
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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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