Provider Demographics
NPI:1275057986
Name:KISTLER, CHARLES AARON IV (ATC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:AARON
Last Name:KISTLER
Suffix:IV
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8259 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8878
Mailing Address - Country:US
Mailing Address - Phone:219-365-6560
Mailing Address - Fax:219-365-6561
Practice Address - Street 1:59 EXECUTIVE PARK S STE 1100
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2208
Practice Address - Country:US
Practice Address - Phone:404-778-6330
Practice Address - Fax:404-778-6370
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0024432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAAT002443OtherATC LICENSE