Provider Demographics
NPI:1255782587
Name:BISTLINE, JOHN EUGENE III (LAT, ATC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:EUGENE
Last Name:BISTLINE
Suffix:III
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 DARBY RD
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-4702
Mailing Address - Country:US
Mailing Address - Phone:610-675-9583
Mailing Address - Fax:
Practice Address - Street 1:501 DARBY RD
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-4702
Practice Address - Country:US
Practice Address - Phone:610-675-9583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0064362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer