Basic Information
| Provider Information | |||||||||
| NPI: | 1275057986 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KISTLER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | AARON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | IV | ||||||||
| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8259 WICKER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463738878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193656560 | ||||||||
| FaxNumber: | 2193656561 | ||||||||
| Practice Location | |||||||||
| Address1: | 59 EXECUTIVE PARK S STE 1100 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047786330 | ||||||||
| FaxNumber: | 4047786370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2017 | ||||||||
| LastUpdateDate: | 08/03/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT002443 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | AT002443 | 01 | GA | ATC LICENSE | OTHER |