Basic Information
| Provider Information | |||||||||
| NPI: | 1245752104 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANDERS | ||||||||
| FirstName: | KYLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 441146 | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301609522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 16784593745 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8199 NAVARRE PKWY STE 12A | ||||||||
| Address2: | |||||||||
| City: | NAVARRE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325666941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509391233 | ||||||||
| FaxNumber: | 8509395097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2017 | ||||||||
| LastUpdateDate: | 07/12/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT29619 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.