MEDICARE: JOHN HARLAN KITTERMAN IV MS, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1164109302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN HARLAN KITTERMAN IV MS, ATC

Provider Business Mailing Address
First Line	:	3735 TOTEM DR
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86406-7959
Country	:	US
Telephone Number	:	626-484-9759
Fax Number	:

Provider Business Practice Location Address
First Line	:	2675 PALO VERDE BLVD S
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-4919
Country	:	US
Telephone Number	:	626-484-9759
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2023
Last Update Date	:	05/13/2025

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