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General NPI Number Information
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NPI Number | 1952880023
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Entity Type | Individual
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Provider Name | KENNETH DILDINE JR. ATC, LAT
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Gender | Male
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Dates
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Enumeration Date | 08/09/2018
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Last Update Date | 05/16/2023
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Provider Practice Location Address
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Address Line | 1230 TOM GINNEVER AVE
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City | O FALLON
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State | MO
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Zip | 63366-4406
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Country | US
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Telephone | 636-359-8884
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Fax |
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Provider Business Mailing Address
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Address Line | 25 DEER RUN TRL
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City | NEW FLORENCE
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State | MO
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Zip | 63363-3519
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Country | US
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Telephone | 636-359-8884
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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 | 2018024370
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License Number State | MO
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