Kenneth Dildine Jr., ATC, LAT

Primary specialty

Athletic TrainerTaxonomy code 2255A2300X

License

2018024370 Issued in MO

Practice address

1230 Tom Ginnever Ave
O Fallon, MO 63366-4406

Phone

(636) 359-8884

NPI assigned

Aug 9, 2018

Last updated

May 16, 2023By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1533772800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1684195200000",
    "number": "1952880023",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "25 DEER RUN TRL",
            "city": "NEW FLORENCE",
            "state": "MO",
            "postal_code": "633633519",
            "telephone_number": "636-359-8884"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1230 TOM GINNEVER AVE",
            "city": "O FALLON",
            "state": "MO",
            "postal_code": "633664406",
            "telephone_number": "636-359-8884"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DILDINE",
        "first_name": "KENNETH",
        "name_suffix": "Jr.",
        "credential": "ATC, LAT",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2018-08-09",
        "last_updated": "2023-05-16",
        "certification_date": "2023-05-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2255A2300X",
            "taxonomy_group": "",
            "desc": "Specialist/Technologist, Athletic Trainer",
            "state": "MO",
            "license": "2018024370",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Athletic Trainer in O'Fallon, MO
• Providers in O'Fallon, MO by specialty
• Athletic Trainer in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 16, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.