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General NPI Number Information
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NPI Number | 1902392582
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Entity Type | Individual
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Provider Name | KEVIN WILLIAM FORTIER LAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 07/06/2018
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Last Update Date | 07/06/2018
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Provider Practice Location Address
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Address Line | 1971 UNIVERSITY BLVD
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City | LYNCHBURG
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State | VA
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Zip | 24515-0002
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Country | US
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Telephone | 434-582-3197
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Fax |
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Provider Business Mailing Address
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Address Line | 301 NORTHWYND CIR APT 204
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City | LYNCHBURG
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State | VA
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Zip | 24502-3415
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Country | US
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Telephone | 518-586-2393
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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 | 0126002915
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License Number State | VA
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