Provider Demographics
NPI:1508472309
Name:KAHL, BRUCE (ATHLETIC TRAINER)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:KAHL
Suffix:
Gender:M
Credentials:ATHLETIC TRAINER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 N UNION WAY
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-6028
Mailing Address - Country:US
Mailing Address - Phone:775-354-7900
Mailing Address - Fax:
Practice Address - Street 1:574 N PARK LN
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4512
Practice Address - Country:US
Practice Address - Phone:208-350-4235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-6982083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Single Specialty