Basic Information
| Provider Information | |||||||||
| NPI: | 1275881997 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLINE | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 48 DOCTORS PARK | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637034928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733358257 | ||||||||
| FaxNumber: | 5733358424 | ||||||||
| Practice Location | |||||||||
| Address1: | 48 DOCTORS PARK | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637034928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733358257 | ||||||||
| FaxNumber: | 5733358424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2012 | ||||||||
| LastUpdateDate: | 08/28/2012 | ||||||||
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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 | 247200000X | 2009018156 | MO | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
ID Information
| ID | Type | State | Issuer | Description | 2009018156 | 01 | MO | LICENSE | OTHER |