Provider Demographics
NPI:1790237717
Name:KWI
Entity Type:Organization
Organization Name:KWI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEAD ATHLETIC TRAINER
Authorized Official - Prefix:
Authorized Official - First Name:KAILY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-636-7301
Mailing Address - Street 1:642 TANGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-5673
Mailing Address - Country:US
Mailing Address - Phone:434-660-7203
Mailing Address - Fax:
Practice Address - Street 1:642 TANGLEWOOD DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-5673
Practice Address - Country:US
Practice Address - Phone:434-660-7203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health